{ "hospital_name": "St Francis Medical Center", "last_updated_on": "2026-03-17", "version": "3.0", "location_name": [ "St Francis Medical Center" ], "hospital_address": [ "3630 East Imperial Highway Lynwood, CA 90262" ], "license_information": { "license_number": "850737566", "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": "Clay Farell" }, "type_2_npi": [ "1114547114" ], "standard_charge_information": [ { "description": "Abd Paracentesis W/Imaging", "code_information": [ { "code": "49083", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3929.6, "discounted_cash": 1160, "minimum": 89.72, "maximum": 3536.64, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1741.22, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 89.72 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1184.03, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 98.84 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 89.72 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "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": 94.21 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 1741.22, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1172.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1483.31, "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": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1509.05, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 98.69 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 89.72 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 98.69 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 128.88 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1230.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 89.72 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 1392.97, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 116.64 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 89.72 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1483.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "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": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1529.19, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": " - Z7510 - ", "code_information": [ { "code": "Z7510", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2290.38, "minimum": 58.4661, "maximum": 2061.342, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 64.32 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 61.39 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 64.32 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 64.32 }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 76.01 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 } ] } ] }, { "description": "ABDOMINAL PAIN - SOI : 1", "code_information": [ { "code": "2511", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3970.07, "maximum": 5161.09, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3970.07 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4029.62, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4168.57, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4367.08, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4367.08, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5161.09, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABDOMINAL PAIN - SOI : 3", "code_information": [ { "code": "2513", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6680.75, "maximum": 8684.98, "payers_information": [ { "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6680.75 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6780.96, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7014.79, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7348.83, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6680.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 7348.83, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6680.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6680.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8684.98, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 6680.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY- SOI : 3", "code_information": [ { "code": "5433", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9671.72, "maximum": 12573.24, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9671.72 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9816.8, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 10155.31, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10638.89, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 10638.89, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12573.24, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABDOMINAL PAIN - SOI : 2", "code_information": [ { "code": "2512", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5154.21, "maximum": 6700.47, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5154.21 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5231.52, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 5411.92, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5669.63, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 5154.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 5669.63, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5154.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5154.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6700.47, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 5154.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5154.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5154.21, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABDOMINAL PAIN - SOI : 4", "code_information": [ { "code": "2514", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10145.16, "maximum": 13188.71, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10145.16 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10297.34, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 10652.42, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11159.68, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 10145.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 11159.68, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10145.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10145.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13188.71, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 10145.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10145.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10145.16, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 7767.69, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5975.15 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6064.78, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 6273.91, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6572.66, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 5975.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 6572.66, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5975.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5975.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7767.69, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 5975.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5975.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5975.15, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABORTION WO D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY - SOI : 3", "code_information": [ { "code": "5643", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6403.11, "maximum": 8324.04, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6403.11 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6499.16, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 6723.27, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7043.42, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6403.11, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 7043.42, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6403.11, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6403.11, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8324.04, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 6403.11, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6403.11, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6403.11, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 5901.57, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4539.67 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4607.77, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4766.65, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4993.64, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4993.64, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5901.57, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY", "code_information": [ { "code": "770", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10255, "minimum": 9450, "maximum": 20689.8, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 10255.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 13844.84, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10460.51, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 10255.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 10255.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 10255.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 10255.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 10255.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 10255.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 11606.25 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10357.95, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20069.11 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10255.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 10255.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16665.09, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13332.07, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 10255.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10870.72, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10255.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 10255.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 12306.53, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10255.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10255.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10255.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13855.91 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10255.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10255.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10217.6 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 19773.24 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 17795.92 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 10255.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20689.8 } ] } ] }, { "description": "ABORTION WITHOUT D&C", "code_information": [ { "code": "779", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8681, "minimum": 5490.67, "maximum": 17974.8, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 8681.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 11719.4, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8854.66, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8681.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 8681.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 8681.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 8681.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 8681.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8681.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 9738.05 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8767.85, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17435.56 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8681.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8681.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14106.69, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11285.35, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 8681.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9201.9, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8681.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 8681.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 10417.25, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8681.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8681.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8681.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 17160.72 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8681.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8681.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5490.67 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 16590.44 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 14931.39 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8681.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17974.8 } ] } ] }, { "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": 22970.81, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17669.85 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17934.9, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 18553.34, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19436.83, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 17669.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 19436.83, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17669.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 17669.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22970.81, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 17669.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17669.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 17669.85, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABORTION WO D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY - SOI : 2", "code_information": [ { "code": "5642", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3745.55, "maximum": 4869.22, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3745.55 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3801.73, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 3932.83, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4120.11, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4120.11, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4869.22, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 3800.47, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2923.44 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2967.29, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 3069.61, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3215.78, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 2923.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 3215.78, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2923.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 2923.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3800.47, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 2923.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2923.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 2923.44, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC", "code_information": [ { "code": "288", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 26872, "minimum": 26872.4, "maximum": 53366.264, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 26872.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 36277.77, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 27409.85, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 26872.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 26872.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 26872.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 26872.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 26872.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 26872.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 31324.27 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 27141.12, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 50946.83 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 26872.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 26872.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 43667.68, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 34934.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 26872.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 28484.74, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 26872.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 26872.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 32246.9, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 26872.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 26872.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 26872.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 44983.58 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 26872.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 26872.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 35790.5 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 53366.26 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 48029.64 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 26872.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 52522.5 } ] } ] }, { "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": 18707.56, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14390.43 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14606.29, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 15109.95, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15829.47, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 14390.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 15829.47, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14390.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14390.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18707.56, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 14390.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14390.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14390.43, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE & SUBACUTE ENDOCARDITIS - SOI : 1", "code_information": [ { "code": "1931", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8140.51, "maximum": 10582.66, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8140.51 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8262.62, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 8547.54, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8954.56, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8140.51, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 8954.56, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8140.51, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8140.51, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10582.66, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 8140.51, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8140.51, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8140.51, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE & SUBACUTE ENDOCARDITIS - SOI : 4", "code_information": [ { "code": "1934", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18754.23, "maximum": 24380.5, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18754.23 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19035.54, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 19691.94, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20629.65, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 20629.65, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24380.5, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CCMCC", "code_information": [ { "code": "290", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9543, "minimum": 9543.35, "maximum": 18824.7, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 9543.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 12883.52, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9734.22, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9543.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 9543.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 9543.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 9543.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 9543.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 9543.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 10761.28 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9638.78, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18259.96 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9543.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9543.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15507.94, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12406.36, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 9543.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10115.95, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9543.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 9543.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 11452.02, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9543.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9543.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9543.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 18824.4 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9543.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9543.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 13007.9 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 18333.68 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 16500.32 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 9543.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18824.7 } ] } ] }, { "description": "ACUTE & SUBACUTE ENDOCARDITIS - SOI : 2", "code_information": [ { "code": "1932", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9819.71, "maximum": 12765.62, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9819.71 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9967.01, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 10310.7, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10801.68, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 10801.68, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12765.62, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION", "code_information": [ { "code": "880", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9840, "minimum": 3360, "maximum": 18935.144, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 9840.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 13285.17, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10037.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9840.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 9840.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 9840.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 9840.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 9840.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 9840.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 11114.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9939.28, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17879.43 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9840.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9840.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15991.41, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12793.13, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 9840.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10431.32, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9840.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 9840.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 11809.04, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9840.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9840.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9840.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 16560.48 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9840.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9840.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7863.14 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 18935.14 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 17041.63 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 9840.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18432.4 } ] } ] }, { "description": "ACUTE ANXIETY & DELIRIUM STATES - SOI : 2", "code_information": [ { "code": "7562", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4969.75, "maximum": 6460.68, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4969.75 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5044.3, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 5218.24, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5466.73, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4969.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 5466.73, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4969.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4969.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6460.68, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4969.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4969.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4969.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE & SUBACUTE ENDOCARDITIS - SOI : 3", "code_information": [ { "code": "1933", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13200.37, "maximum": 17160.48, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13200.37 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13398.38, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 13860.39, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14520.41, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 14520.41, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17160.48, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE AND SUBACUTE ENDOCARDITIS WITH CC", "code_information": [ { "code": "289", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17124, "minimum": 9218.14, "maximum": 33660.068, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 17124.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 23118.25, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 17467.09, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 17124.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 17124.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 17124.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 17124.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 17124.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 17124.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 19757.37 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 17295.85, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29407.98 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 17124.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 17124.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 27827.52, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 22262.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 17124.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18152.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 17124.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 17124.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 20549.56, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 17124.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17124.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17124.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 25635.26 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 17124.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17124.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9218.14 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 33660.07 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 30294.06 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 17124.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30317.5 } ] } ] }, { "description": "ACUTE ANXIETY & DELIRIUM STATES - SOI : 3", "code_information": [ { "code": "7563", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7029.52, "maximum": 9138.38, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7029.52 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7134.96, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7381, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7732.47, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 7029.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 7732.47, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7029.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7029.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9138.38, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 7029.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7029.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7029.52, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE ANXIETY & DELIRIUM STATES - SOI : 4", "code_information": [ { "code": "7564", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10975.22, "maximum": 14267.79, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10975.22 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11139.85, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 11523.98, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12072.74, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 12072.74, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14267.79, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE ANXIETY & DELIRIUM STATES - SOI : 1", "code_information": [ { "code": "7561", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3331.89, "maximum": 4331.46, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3331.89 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3381.87, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 3498.48, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3665.08, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3331.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 3665.08, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3331.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3331.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4331.46, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 3331.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3331.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3331.89, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE BRONCHITIS AND RELATED SYMPTOMS - SOI : 4", "code_information": [ { "code": "1454", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10920.09, "maximum": 14196.12, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10920.09 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11083.89, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 11466.09, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12012.1, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 10920.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 12012.1, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10920.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10920.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14196.12, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 10920.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10920.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10920.09, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE KIDNEY INJURY - SOI : 2", "code_information": [ { "code": "4692", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5463.76, "maximum": 7102.89, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5463.76 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5545.72, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 5736.95, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6010.14, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 6010.14, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7102.89, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE BRONCHITIS AND RELATED SYMPTOMS - SOI : 1", "code_information": [ { "code": "1451", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3855.58, "maximum": 5012.25, "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4241.14, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3855.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4241.14, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3855.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3855.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5012.25, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 3855.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3855.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3855.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3855.58 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3913.41, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4048.36, "additional_payer_notes": "105% 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": 6335.26, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4873.28 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4946.38, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 5116.94, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5360.61, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4873.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 5360.61, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4873.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4873.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6335.26, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4873.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4873.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4873.28, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE LEUKEMIA - SOI : 1", "code_information": [ { "code": "6901", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8594.23, "maximum": 11172.5, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8594.23 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8723.14, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 9023.94, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9453.65, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8594.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 9453.65, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8594.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8594.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11172.5, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 8594.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8594.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8594.23, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE LEUKEMIA - SOI : 4", "code_information": [ { "code": "6904", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 45078.63, "maximum": 58602.22, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45078.63 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45754.81, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 47332.56, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 49586.49, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 45078.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 49586.49, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45078.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 45078.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 58602.22, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 45078.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45078.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 45078.63, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE BRONCHITIS AND RELATED SYMPTOMS - SOI : 3", "code_information": [ { "code": "1453", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6782.52, "maximum": 8817.28, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6782.52 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6884.26, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7121.65, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7460.77, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6782.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 7460.77, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6782.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6782.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8817.28, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 6782.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6782.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6782.52, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE KIDNEY INJURY - SOI : 3", "code_information": [ { "code": "4693", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8886.82, "maximum": 11552.87, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8886.82 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9020.12, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 9331.16, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9775.5, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8886.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 9775.5, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8886.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8886.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11552.87, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 8886.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8886.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8886.82, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE MAJOR EYE INFECTIONS WITH CCMCC", "code_information": [ { "code": "121", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11822, "minimum": 5779.15, "maximum": 22940.276, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 11822, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 15959.74, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 12058.44, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11822, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 11822, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 11822, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 11822.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 11822.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 11822, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 13465.2 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11940.22, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21695.51 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11822, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 11822.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 19210.8, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 15368.64, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 11822, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12531.32, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11822, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 11822.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 14186.44, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11822.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11822.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11822, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 22226.36 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11822, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11822.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5779.15 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 22940.28 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 20646.25 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 11822, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22366.5 } ] } ] }, { "description": "ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "836", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12370, "minimum": 10800, "maximum": 24493.76, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 12370.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 16699.82, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 12617.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 12370.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 12370.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 12370.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 12370.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 12370.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 12370.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 14115.71 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12493.9, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23700.59 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 12370.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 12370.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20101.64, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16081.31, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 12370.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13112.41, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 12370.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 12370.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 14844.29, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 12370.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12370.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12370.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 24493.76 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12370.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12370.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16883.8 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 24048.54 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 21643.69 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 12370.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24433.6 } ] } ] }, { "description": "ACUTE KIDNEY INJURY - SOI : 1", "code_information": [ { "code": "4691", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4013.54, "maximum": 5217.6, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4013.54 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4073.74, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4214.22, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4414.89, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4013.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4414.89, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4013.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4013.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5217.6, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4013.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4013.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4013.54, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE KIDNEY INJURY - SOI : 4", "code_information": [ { "code": "4694", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 17070.79, "maximum": 22192.03, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17070.79 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17326.85, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 17924.33, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18777.87, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 17070.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 18777.87, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17070.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 17070.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22192.03, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 17070.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17070.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 17070.79, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION - SOI : 1", "code_information": [ { "code": "1901", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6639.41, "maximum": 8631.23, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6639.41 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6739, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 6971.38, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7303.35, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6639.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 7303.35, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6639.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6639.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8631.23, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 6639.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6639.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6639.41, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE MAJOR EYE INFECTIONS WITHOUT CCMCC", "code_information": [ { "code": "122", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8139, "minimum": 3705.93, "maximum": 15495.976, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 8139.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 10988.54, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8302.45, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8139.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 8139.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 8139.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 8139.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 8139.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8139.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 9095.64 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8221.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12651.42 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8139.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8139.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13226.95, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10581.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 8139.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8628.04, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8139.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 8139.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 9767.59, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8139.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8139.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8139.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12915.65 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8139.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8139.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 3705.93 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 15495.98 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 13946.38 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8139.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13042.7 } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION - SOI : 3", "code_information": [ { "code": "1903", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9493.2, "maximum": 12341.16, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9493.2 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9635.6, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 9967.86, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10442.52, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 9493.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 10442.52, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9493.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9493.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12341.16, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 9493.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9493.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9493.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE LEUKEMIA - SOI : 2", "code_information": [ { "code": "6902", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15211.37, "maximum": 19774.78, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15211.37 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15439.54, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 15971.94, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16732.51, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 15211.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 16732.51, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15211.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15211.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19774.78, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 15211.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15211.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15211.37, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION - SOI : 4", "code_information": [ { "code": "1904", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15137.17, "maximum": 19678.32, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15137.17 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15364.23, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 15894.03, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16650.89, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 16650.89, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19678.32, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION - SOI : 2", "code_information": [ { "code": "1902", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7316.81, "maximum": 9511.85, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7426.56, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7682.65, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8048.49, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 8048.49, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9511.85, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC", "code_information": [ { "code": "280", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16121, "minimum": 16121.86, "maximum": 31632.852, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 16121.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 21764.51, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 16444.34, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 16121.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 16121.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 16121.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 16121.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 16121.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 16121.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 18567.46 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16283.12, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30614.75 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 16121.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 16121.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 26198.02, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 20958.42, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 16121.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17089.21, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 16121.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 18450, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 4500, "10th_percentile": 4500, "90th_percentile": 18000, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 16121.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 19346.23, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 16121.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16121.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16121.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 27522.73 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16121.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16121.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18235.2 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 31632.85 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 28469.57 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 16121.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31561.6 } ] } ] }, { "description": "ACUTE LEUKEMIA - SOI : 3", "code_information": [ { "code": "6903", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 25746.65, "maximum": 33470.65, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25746.65 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26132.85, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 27033.98, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28321.32, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 25746.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 28321.32, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25746.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 25746.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33470.65, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 25746.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25746.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 25746.65, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC", "code_information": [ { "code": "281", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9439, "minimum": 9439.95, "maximum": 18124.652, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 9439.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 12743.93, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9628.75, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9439.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 9439.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 9439.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 9439.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 9439.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 9439.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 10638.58 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9534.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17193.06 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9439.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9439.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15339.92, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12271.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 9439.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10006.35, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9439.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 10800, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 9000, "10th_percentile": 4500, "90th_percentile": 13500, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 9439.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 11327.94, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9439.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9439.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9439.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 15838.8 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9439.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9439.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12293.3 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 18124.65 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 16312.19 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 9439.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17724.8 } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CCMCC", "code_information": [ { "code": "282", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7528, "minimum": 7528.05, "maximum": 14259.532, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 7528.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 10162.87, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7678.61, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7528.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 7528.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 7528.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 7528.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 7528.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 7528.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8369.88 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7603.33, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13524.32 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7528.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7528.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12233.08, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9786.47, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 7528.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7979.73, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7528.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 7528.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 9033.66, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7528.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7528.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7528.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12457.66 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7528.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7528.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11026.8 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 14259.53 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 12833.58 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 7528.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13942.6 } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC", "code_information": [ { "code": "283", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19796, "minimum": 14400, "maximum": 39061.376, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 19796.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 26725.17, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 20192.33, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 19796.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 19796.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 19796.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 19796.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 19796.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 19796.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 22927.76 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 19994.36, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36471.32 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 19796.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 19796.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 32169.18, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 25735.35, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 19796.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20984.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 19796.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 19796.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 23755.7, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 19796.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19796.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19796.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 34200.01 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19796.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19796.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 33847.7 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 39061.38 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 35155.24 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 19796.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37599.3 } ] } ] }, { "description": "ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC", "code_information": [ { "code": "835", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20820, "minimum": 19800, "maximum": 41131.976, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 20820.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 28107.89, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 21237.11, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 20820.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 20820.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 20820.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 20820.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 20820.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 20820.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 24143.14 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 21028.91, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39838 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 20820.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 20820.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 33833.57, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 27066.86, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 20820.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22069.94, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 20820.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 20820.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 24984.79, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 20820.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20820.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20820.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 38781.64 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 20820.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20820.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24155.6 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 41131.98 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 37018.78 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 20820.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 41070.1 } ] } ] }, { "description": "ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES - SOI : 3", "code_information": [ { "code": "7553", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5442.55, "maximum": 7075.32, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5442.55 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5524.19, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 5714.68, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5986.81, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 5986.81, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7075.32, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC", "code_information": [ { "code": "284", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7226, "minimum": 7200, "maximum": 14248.3, "payers_information": [ { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7226.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7226.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11743.27, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9394.62, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 7226.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7660.23, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7226.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 7226.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 8671.96, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7226.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7226.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7226.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12832.38 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7226.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7226.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9845.37 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 13650.18 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 12285.17 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 7226.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14248.3 }, { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 7226.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 9755.95, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7371.16, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7226.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 7226.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 7226.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 7226.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 7226.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 7226.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8012.22 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7298.9, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13820.85 } ] } ] }, { "description": "ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH MCC", "code_information": [ { "code": "834", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 54026, "minimum": 42300, "maximum": 109007, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 54026.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 72935.53, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 55106.83, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 54026.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 54026.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 54026.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 54026.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 54026.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 54026.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 63545.59 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 54566.56, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 103093.06 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 54026.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 54026.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 87792.77, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 70234.22, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 54026.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 57267.88, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 54026.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 54026.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 64831.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 54026.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 54026.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 54026.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 97131.91 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 54026.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 54026.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 109007 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 108260.83 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 97434.75 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 54026.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 106281.5 } ] } ] }, { "description": "ADRENAL PROCEDURES - SOI : 1", "code_information": [ { "code": "4011", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10090.03, "maximum": 13117.04, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10090.03 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10241.38, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 10594.53, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11099.03, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 10090.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 11099.03, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10090.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10090.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13117.04, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 10090.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10090.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10090.03, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CCMCC", "code_information": [ { "code": "285", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6316, "minimum": 5850, "maximum": 11810.308, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 6316.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 8527.32, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6442.86, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6316.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 6316.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 6316.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 6316.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 6316.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 6316.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 6932.27 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6379.7, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10471.05 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6316.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6316.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 10264.36, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 8211.49, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 6316.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6695.52, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6316.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 6316.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 7579.84, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6316.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6316.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6316.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 8478.01 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6316.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6316.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7459.74 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 11810.31 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 10629.28 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 6316.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10794.9 } ] } ] }, { "description": "ADRENAL PROCEDURES - SOI : 2", "code_information": [ { "code": "4012", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13076.33, "maximum": 16999.23, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13076.33 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13272.47, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 13730.15, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14383.96, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 14383.96, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16999.23, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES - SOI : 2", "code_information": [ { "code": "7552", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2936.48, "maximum": 3817.42, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2936.48 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2980.53, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 3083.3, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3230.13, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 2936.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 3230.13, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2936.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 2936.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3817.42, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 2936.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2936.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 2936.48, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC", "code_information": [ { "code": "559", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18665, "minimum": 18665.86, "maximum": 36775.828, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 18665.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 25198.91, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 19039.22, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 18665.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 18665.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 18665.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 18665.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 18665.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 18665.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 21586.22 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18852.56, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34622.99 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 18665.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 18665.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 30332.02, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 24265.62, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 18665.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19785.85, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 18665.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 18665.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 22399.03, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 18665.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18665.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18665.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 32102.62 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18665.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18665.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24664.3 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 36775.83 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 33098.25 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 18665.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35693.8 } ] } ] }, { "description": "ADRENAL PROCEDURES - SOI : 3", "code_information": [ { "code": "4013", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 24086.53, "maximum": 31312.49, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24086.53 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24447.83, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 25290.86, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26495.18, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 24086.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 26495.18, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24086.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 24086.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31312.49, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 24086.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24086.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 24086.53, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ADRENAL AND PITUITARY PROCEDURES WITH CCMCC", "code_information": [ { "code": "614", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21854, "minimum": 12150, "maximum": 43821.7, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 21854.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 29503.76, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 22291.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 21854.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 21854.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 21854.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 21854.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 21854.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 21854.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 25370.09 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 22073.15, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42507.05 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 21854.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 21854.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 35513.79, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 28411.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 21854.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 23165.88, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 21854.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 21854.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 26225.57, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 21854.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21854.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 21854.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 39074.82 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 21854.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21854.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 32543 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 43222.3 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 38900.07 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 21854.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 43821.7 } ] } ] }, { "description": "ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES - SOI : 1", "code_information": [ { "code": "7551", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2180.63, "maximum": 2834.82, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2180.63 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2213.34, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 2289.66, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2398.69, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 2180.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 2398.69, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2180.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 2180.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2834.82, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 2180.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2180.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 2180.63, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AICD GENERATOR PROCEDURES", "code_information": [ { "code": "245", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 44978, "minimum": 19350, "maximum": 93965.7, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 44978.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 60721.54, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 45878.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 44978.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 44978.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 44978.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 44978.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 44978.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 44978.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 52809.78 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 45428.69, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 91146.73 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 44978.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 44978.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 73090.75, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 58472.6, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 44978.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 47677.63, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 44978.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 44978.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 53974.7, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 44978.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 44978.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 44978.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 78611.1 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 44978.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 44978.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 64929.2 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 89970.53 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 80973.48 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 44978.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 93965.7 } ] } ] }, { "description": "ADRENAL PROCEDURES - SOI : 4", "code_information": [ { "code": "4014", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 45294.89, "maximum": 58883.36, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45294.89 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45974.31, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 47559.63, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 49824.38, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 49824.38, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 58883.36, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ADRENAL AND PITUITARY PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "615", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14124, "minimum": 6750, "maximum": 27594.196, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 14124.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 19067.56, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 14406.58, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 14124.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 14124.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 14124.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 14124.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 14124.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 14124.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 16196.9 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 14265.34, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26727.77 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 14124.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 14124.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 22951.7, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 18361.36, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 14124.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14971.55, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 14124.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 14124.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 16948.94, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 14124.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14124.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14124.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 25520.76 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14124.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14124.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19735 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 27594.2 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 24834.78 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 14124.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27554.4 } ] } ] }, { "description": "ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES - SOI : 4", "code_information": [ { "code": "7554", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8638.75, "maximum": 11230.38, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8638.75 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8768.33, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 9070.69, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9502.63, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8638.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 9502.63, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8638.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8638.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11230.38, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 8638.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8638.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8638.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AFTERCARE WITHOUT CCMCC", "code_information": [ { "code": "950", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6597, "minimum": 6597.46, "maximum": 23573.8, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 6597.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 8906.57, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6729.41, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6597.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 6597.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 6597.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 6597.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 6597.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 6597.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 7265.63 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6663.43, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10931.71 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6597.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6597.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 10720.87, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 8576.7, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 6597.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6993.31, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6597.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 6597.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 7916.95, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6597.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6597.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6597.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 11078.48 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6597.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6597.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23573.8 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 12378.24 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 11140.42 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 6597.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11269.8 } ] } ] }, { "description": "AFTERCARE WITH CCMCC", "code_information": [ { "code": "949", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12079, "minimum": 12079.5, "maximum": 29527.8, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 12079.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 16307.39, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 12321.09, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 12079.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 12079.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 12079.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 12079.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 12079.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 12079.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 13770.78 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12200.3, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20125.08 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 12079.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 12079.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 19629.27, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 15703.42, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 12079.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12804.27, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 12079.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 12079.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 14495.46, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 12079.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12079.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12079.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 18611.02 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12079.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12079.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 29527.8 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 23460.88 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 21114.8 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 12079.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20747.5 } ] } ] }, { "description": "AICD LEAD PROCEDURES", "code_information": [ { "code": "265", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 35768, "minimum": 18450, "maximum": 71350.904, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 35768.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 48287.64, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 36483.97, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 35768.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 35768.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 35768.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 35768.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 35768.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 35768.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 41880.67 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 36126.29, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 66534.05 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 35768.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 35768.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 58124.01, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 46499.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 35768.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 37914.72, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 35768.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 35768.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 42922.34, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 35768.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 35768.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 35768.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 61309.85 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 35768.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 35768.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 47396.7 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 71350.9 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 64215.81 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 35768.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 68591.8 } ] } ] }, { "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": 5892.89, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4532.99 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4600.98, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4759.64, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4986.29, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4986.29, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5892.89, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC", "code_information": [ { "code": "560", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11459, "minimum": 11459.16, "maximum": 22206.692, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 11459.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 15469.87, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11688.38, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11459.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 11459.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 11459.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 11459.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 11459.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 11459.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 13034.61 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11573.79, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21238.64 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11459.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 11459.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18621.14, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14896.91, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 11459.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12146.75, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11459.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 11459.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 13750.99, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11459.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11459.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11459.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 19639.76 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11459.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11459.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18669.7 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 22206.69 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 19986.02 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 11459.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21895.5 } ] } ] }, { "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": 5013.63, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3856.64 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3914.49, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4049.47, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4242.3, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3856.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4242.3, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3856.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3856.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5013.63, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 3856.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3856.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3856.64, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 8919.26, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6860.97 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6963.88, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7204.02, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7547.07, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6860.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 7547.07, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6860.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6860.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8919.26, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 6860.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6860.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6860.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CCMCC", "code_information": [ { "code": "561", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8316, "minimum": 8316.22, "maximum": 15852.908, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 8316.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 11226.9, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8482.54, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8316.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 8316.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 8316.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 8316.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 8316.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8316.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 9305.14 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8399.38, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15249.56 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8316.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8316.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13513.86, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10811.09, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 8316.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8815.19, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8316.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 8316.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 9979.46, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8316.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8316.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8316.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13534.97 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8316.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8316.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11959.3 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 15852.91 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 14267.62 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8316.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15721.2 } ] } ] }, { "description": "ALCOHOL ABUSE & DEPENDENCE - SOI : 3", "code_information": [ { "code": "7753", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8305.88, "maximum": 10797.64, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8305.88 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8430.47, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 8721.17, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9136.47, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8305.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 9136.47, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8305.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8305.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10797.64, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 8305.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8305.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8305.88, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALCOHOL ABUSE & DEPENDENCE - SOI : 1", "code_information": [ { "code": "7751", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3288.43, "maximum": 4274.96, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3288.43 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3337.76, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 3452.85, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3617.27, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3288.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 3617.27, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3288.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3288.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4274.96, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 3288.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3288.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3288.43, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY", "code_information": [ { "code": "895", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14283, "minimum": 8809.96, "maximum": 34200, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 14283.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 19282.21, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 14568.76, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 14283.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 14283.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 14283.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 14283.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 14283.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 14283.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 16385.57 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 14425.93, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27005.67 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 14283.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 14283.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 23210.07, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 18568.06, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 14283.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15140.09, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 14283.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 14283.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 17139.74, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 14283.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14283.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14283.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 27909.59 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14283.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14283.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8809.96 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 27915.63 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 25124.07 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 14283.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27840.9 } ] } ] }, { "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": 24631.32, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18947.17 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19231.38, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 19894.53, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20841.89, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 18947.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 20841.89, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18947.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18947.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24631.32, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 18947.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18947.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18947.17, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALCOHOL ABUSE & DEPENDENCE - SOI : 4", "code_information": [ { "code": "7754", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 19303.36, "maximum": 25094.37, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19303.36 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19592.91, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 20268.53, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21233.7, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 19303.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 21233.7, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19303.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 19303.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25094.37, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 19303.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19303.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 19303.36, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALCOHOL ABUSE & DEPENDENCE - SOI : 2", "code_information": [ { "code": "7752", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4746.07, "maximum": 6169.89, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4746.07 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4817.26, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4983.37, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5220.68, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4746.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 5220.68, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4746.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4746.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6169.89, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4746.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4746.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4746.07, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC", "code_information": [ { "code": "896", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17497, "minimum": 14032.5, "maximum": 34413.372, "payers_information": [ { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 17497.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 17497.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 20996.71, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 17497.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17497.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17497.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 30846.62 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 17497.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17497.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14032.5 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 34413.37 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 30972.03 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 17497.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34242 }, { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 17497.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 23621.3, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 17847.25, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 17497.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 17497.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 17497.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 17497.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 17497.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 17497.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 20199.53 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 17672.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33214.74 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 17497.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 17497.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 28433.05, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 22746.44, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 17497.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18547.14, "additional_payer_notes": "106.00% of Medicare Rates" } ] } ] }, { "description": "ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA", "code_information": [ { "code": "894", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6492, "minimum": 4618.05, "maximum": 12165.268, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 6492.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 8764.35, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6621.95, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6492.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 6492.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 6492.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 6492.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 6492.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 6492.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 7140.62 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6557.03, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11640.49 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6492.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6492.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 10549.68, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 8439.74, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 6492.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6881.64, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6492.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 6492.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 7790.53, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6492.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6492.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6492.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 9966.47 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6492.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6492.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 4618.05 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 12165.27 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 10948.74 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 6492.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12000.5 } ] } ] }, { "description": "ALCOHOLIC LIVER DISEASE - SOI : 3", "code_information": [ { "code": "2803", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9753.98, "maximum": 12680.17, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9753.98 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9900.29, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 10241.68, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10729.38, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 9753.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 10729.38, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9753.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9753.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12680.17, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 9753.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9753.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9753.98, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALCOHOLIC LIVER DISEASE - SOI : 2", "code_information": [ { "code": "2802", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6415.73, "maximum": 8340.45, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6415.73 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6511.97, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 6736.52, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7057.3, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6415.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 7057.3, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6415.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6415.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8340.45, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 6415.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6415.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6415.73, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC", "code_information": [ { "code": "897", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9085, "minimum": 9085.86, "maximum": 17408.816, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 9085.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 12265.91, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9267.58, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9085.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 9085.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 9085.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 9085.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 9085.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 9085.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 10218.41 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9176.72, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16454.5 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9085.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9085.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14764.52, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11811.62, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 9085.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9631.01, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9085.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 9085.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 10903.03, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9085.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9085.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9085.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 14843.02 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9085.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9085.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 17408.82 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 15667.93 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 9085.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16963.4 } ] } ] }, { "description": "ALLERGIC REACTIONS - SOI : 4", "code_information": [ { "code": "8114", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15162.61, "maximum": 19711.39, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15162.61 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15390.05, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 15920.74, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16678.87, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 15162.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 16678.87, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15162.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15162.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19711.39, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 15162.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15162.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15162.61, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLERGIC REACTIONS - SOI : 2", "code_information": [ { "code": "8112", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4082.45, "maximum": 5307.18, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4082.45 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4143.69, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4286.57, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4490.69, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4082.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4490.69, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4082.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4082.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5307.18, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4082.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4082.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4082.45, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALCOHOLIC LIVER DISEASE - SOI : 1", "code_information": [ { "code": "2801", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4881.76, "maximum": 6346.29, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4881.76 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4954.99, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 5125.85, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5369.94, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4881.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 5369.94, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4881.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4881.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6346.29, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4881.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4881.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4881.76, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLOGENEIC BONE MARROW TRANSPLANT- SOI : 2", "code_information": [ { "code": "0072", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 66446.01, "maximum": 86379.81, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66446.01 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 67442.7, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 69768.31, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 73090.61, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 66446.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 73090.61, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66446.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 66446.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 86379.81, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 66446.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66446.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 66446.01, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLERGIC REACTIONS WITH MCC", "code_information": [ { "code": "915", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16877, "minimum": 16650, "maximum": 33417.1, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 16877.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 22785.08, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 17215.36, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 16877.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 16877.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 16877.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 16877.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 16877.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 16877.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 19464.52 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 17046.58, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32414.59 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 16877.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 16877.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 27426.49, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 21941.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 16877.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17890.47, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 16877.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 16650, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 22500, "10th_percentile": 22500, "90th_percentile": 22500, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 16877.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 20253.41, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 16877.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16877.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16877.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 30775.5 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16877.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16877.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18431.5 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 33161.15 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 29845.04 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 16877.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33417.1 } ] } ] }, { "description": "ALLOGENEIC BONE MARROW TRANSPLANT- SOI : 1", "code_information": [ { "code": "0071", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 55309.66, "maximum": 71902.56, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55309.66 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 56139.3, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 58075.14, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 60840.63, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 55309.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 60840.63, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55309.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 55309.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 71902.56, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 55309.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55309.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 55309.66, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALCOHOLIC LIVER DISEASE - SOI : 4", "code_information": [ { "code": "2804", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 19238.69, "maximum": 25010.3, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19238.69 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19527.27, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 20200.62, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21162.56, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 19238.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 21162.56, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19238.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 19238.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25010.3, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 19238.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19238.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 19238.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLERGIC REACTIONS WITHOUT MCC", "code_information": [ { "code": "916", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6973, "minimum": 5287.18, "maximum": 13139.436, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 6973.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 9414.89, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7113.47, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6973.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 6973.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 6973.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 6973.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 6973.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 6973.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 7712.42 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7043.73, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12386.51 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6973.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6973.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11332.73, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9066.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 6973.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7392.43, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6973.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 6973.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 8368.79, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6973.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6973.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6973.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 11428.92 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6973.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6973.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5287.18 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 13139.44 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 11825.49 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 6973.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12769.6 } ] } ] }, { "description": "ALTERATION IN CONSCIOUSNESS - SOI : 1", "code_information": [ { "code": "0521", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4892.36, "maximum": 6360.07, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4892.36 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4965.75, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 5136.98, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5381.6, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4892.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 5381.6, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4892.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4892.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6360.07, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4892.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4892.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4892.36, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLERGIC REACTIONS - SOI : 1", "code_information": [ { "code": "8111", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2829.41, "maximum": 3678.23, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2829.41 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2871.85, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 2970.88, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3112.35, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 3112.35, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3678.23, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLOGENEIC BONE MARROW TRANSPLANT", "code_information": [ { "code": "014", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 117704, "minimum": 117704, "maximum": 251927.5, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 117704, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 158900.97, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 120058.08, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 117704, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 117704, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 117704, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 117704.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 117704.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 117704, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 139107.19 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 118881.04, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 244369.68 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 117704, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 117704.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 191269.68, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 153015.75, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 117704, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 124766.24, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 117704, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 117704.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 141245.3, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 117704.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 117704.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 117704, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 198824.63 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 117704, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 117704.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 140592 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 236992.99 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 213293.69 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 117704, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 251927.5 } ] } ] }, { "description": "ALLERGIC REACTIONS - SOI : 3", "code_information": [ { "code": "8113", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8023.9, "maximum": 10431.07, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8023.9 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8144.26, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 8425.09, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8826.29, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8023.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 8826.29, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8023.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8023.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10431.07, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 8023.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8023.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8023.9, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLOGENEIC BONE MARROW TRANSPLANT- SOI : 4", "code_information": [ { "code": "0074", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 149835.59, "maximum": 194786.27, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 149835.59 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 152083.12, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 157327.37, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 164819.15, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 149835.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 164819.15, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 149835.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 149835.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 194786.27, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 149835.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 149835.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 149835.59, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLOGENEIC BONE MARROW TRANSPLANT- SOI : 3", "code_information": [ { "code": "0073", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 89273.14, "maximum": 116055.08, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 89273.14 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 90612.24, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 93736.8, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 98200.45, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 89273.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 98200.45, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 89273.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 89273.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 116055.08, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 89273.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 89273.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 89273.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALTERATION IN CONSCIOUSNESS - SOI : 3", "code_information": [ { "code": "0523", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9100.96, "maximum": 11831.25, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9100.96 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9237.47, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 9556.01, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10011.06, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 9100.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 10011.06, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9100.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9100.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11831.25, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 9100.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9100.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9100.96, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC", "code_information": [ { "code": "475", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 22673, "minimum": 22673.06, "maximum": 44876.804, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 22673.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 30608.63, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 23126.56, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 22673.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 22673.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 22673.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 22673.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 22673.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 22673.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 26341.23 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 22899.83, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40237.15 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 22673.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 22673.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 36843.72, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 29474.98, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 22673.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 24033.49, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 22673.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 22673.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 27207.67, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 22673.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 22673.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 22673.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 37206.43 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 22673.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 22673.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 25028.2 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 44876.8 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 40389.12 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 22673.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 41481.6 } ] } ] }, { "description": "AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CCMCC", "code_information": [ { "code": "476", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11986, "minimum": 10299, "maximum": 23273.544, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 11986.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 16182.29, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 12226.64, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11986.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 11986.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 11986.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 11986.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 11986.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 11986.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 13660.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12106.77, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21693.66 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11986.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 11986.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 19478.68, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 15582.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 11986.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12706.11, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11986.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 11986.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 14384.26, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11986.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11986.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11986.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 20416.96 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11986.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11986.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10299 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 23273.54 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 20946.19 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 11986.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22364.6 } ] } ] }, { "description": "ALTERATION IN CONSCIOUSNESS - SOI : 2", "code_information": [ { "code": "0522", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6485.69, "maximum": 8431.4, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6485.69 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6582.98, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 6809.97, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7134.26, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6485.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 7134.26, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6485.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6485.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8431.4, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 6485.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6485.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6485.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMPUTATION OF LOWER LIMB EXCEPT TOES - SOI : 3", "code_information": [ { "code": "3053", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18500.87, "maximum": 24051.13, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18500.87 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18778.38, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 19425.91, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20350.96, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 18500.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 20350.96, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18500.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18500.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24051.13, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 18500.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18500.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18500.87, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALTERATION IN CONSCIOUSNESS - SOI : 4", "code_information": [ { "code": "0524", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15262.26, "maximum": 19840.94, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15262.26 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15491.19, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 16025.37, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16788.49, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 15262.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 16788.49, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15262.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15262.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19840.94, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 15262.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15262.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15262.26, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 34492, "minimum": 29390.1, "maximum": 74318, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 34492.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 46565.17, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 35182.55, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 34492.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 34492.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 34492.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 34492.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 34492.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 34492.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 40366.66 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 34837.63, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 72088.46 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 34492.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 34492.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 56050.67, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 44840.54, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 34492.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 36562.26, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 34492.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 45000, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 54000, "10th_percentile": 54000, "90th_percentile": 54000, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 34492.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 41391.26, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 34492.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 34492.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 34492.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 68658.5 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 34492.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 34492.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 29390.1 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 68771.53 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 61894.38 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 34492.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 74318 } ] } ] }, { "description": "ANAL AND PERINEAL PROCEDURES- SOI : 1", "code_information": [ { "code": "2261", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6668.03, "maximum": 8668.44, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6668.03 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6768.05, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7001.43, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7334.83, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 7334.83, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8668.44, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS - SOI : 3", "code_information": [ { "code": "1983", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6257.77, "maximum": 8135.1, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6257.77 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6351.64, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 6570.66, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6883.55, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 6883.55, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8135.1, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANOXIC & OTHER SEVERE BRAIN DAMAGE - SOI : 2", "code_information": [ { "code": "0592", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7339.07, "maximum": 9540.79, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7339.07 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7449.16, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7706.02, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8072.98, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 7339.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 8072.98, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7339.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7339.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9540.79, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 7339.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7339.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7339.07, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC", "code_information": [ { "code": "239", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 48483, "minimum": 47370.3, "maximum": 97055.924, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 48483.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 65453.06, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 49453.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 48483.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 48483.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 48483.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 48483.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 48483.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 48483.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 56968.68 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 48968.64, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 93946.34 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 48483.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 48483.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 78786.09, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 63028.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 48483.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 51392.83, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 48483.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 48483.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 58180.5, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 48483.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 48483.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 48483.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 83388.76 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 48483.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 48483.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 47370.3 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 97055.92 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 87350.33 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 48483.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 96851.9 } ] } ] }, { "description": "ANOXIC & OTHER SEVERE BRAIN DAMAGE - SOI : 4", "code_information": [ { "code": "0594", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16561.94, "maximum": 21530.52, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16561.94 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16810.37, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 17390.04, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18218.13, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 16561.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 18218.13, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16561.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16561.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21530.52, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 16561.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16561.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16561.94, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Amputation Of Finger/Thumb - 26952 - OR36026952", "code_information": [ { "code": "26952", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14942, "discounted_cash": 4187, "minimum": 445.91, "maximum": 13878.18, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6281.57, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 445.91 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4271.46, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 490.5 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 445.91 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "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": 468.21 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6281.57, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4229.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5351.14, "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": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5444.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 490.5 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 445.91 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 490.5 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 445.91 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4438.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 445.91 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 5025.25, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 579.68 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 445.91 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 445.91 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5351.18, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 445.91 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "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": 13978, "minimum": 13978.77, "maximum": 29033.1, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 13978.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 18871.34, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 14258.38, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 13978.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 13978.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 13978.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 13978.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 13978.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 13978.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 16024.43 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 14118.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28162.11 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 13978.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 13978.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 22715.5, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 18172.4, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 13978.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14817.53, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13978.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 13978.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 16774.52, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13978.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13978.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13978.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 24183.23 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13978.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13978.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20061.8 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 27300.37 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 24570.33 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 13978.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29033.1 } ] } ] }, { "description": "AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC", "code_information": [ { "code": "269", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 41670, "minimum": 6750, "maximum": 83281.504, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 41670.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 56254.72, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 42503.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 41670.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 41670.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 41670.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 41670.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 41670.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 41670.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 48883.54 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 42086.9, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 77603.78 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 41670.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 41670.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 67714.01, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 54171.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 41670.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 44170.41, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 41670.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 41670.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 50004.19, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 41670.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 41670.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 41670.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 72143.73 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 41670.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 41670.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8210.26 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 83281.5 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 74953.35 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 41670.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 80003.9 } ] } ] }, { "description": "ANAL AND PERINEAL PROCEDURES- SOI : 2", "code_information": [ { "code": "2262", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8216.84, "maximum": 10681.89, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8216.84 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8340.09, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 8627.68, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9038.52, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8216.84, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 9038.52, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8216.84, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8216.84, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10681.89, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 8216.84, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8216.84, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8216.84, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMPUTATION OF LOWER LIMB EXCEPT TOES - SOI : 1", "code_information": [ { "code": "3051", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9407.33, "maximum": 12229.53, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9407.33 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9548.44, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 9877.7, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10348.06, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 9407.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 10348.06, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9407.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9407.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12229.53, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 9407.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9407.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9407.33, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS - SOI : 1", "code_information": [ { "code": "2331", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8727.8, "maximum": 11346.14, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8727.8 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8858.72, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 9164.19, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9600.58, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8727.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 9600.58, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8727.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8727.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11346.14, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 8727.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8727.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8727.8, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 28280, "minimum": 24945.6, "maximum": 56211.86, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 28280, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 38178.01, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 28845.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 28280, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 28280, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 28280, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 28280.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 28280.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 28280, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 32994.54 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 28562.8, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 54317.19 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 28280, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 28280.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 45955.02, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 36764.01, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 28280, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 29976.8, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 28280, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 28280.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 33936.01, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 28280.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 28280.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 28280, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 48734.23 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 28280, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 28280.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24945.6 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 56211.86 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 50590.67 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 28280, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 55997.1 } ] } ] }, { "description": "ANAL AND PERINEAL PROCEDURES- SOI : 3", "code_information": [ { "code": "2263", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12875.97, "maximum": 16738.76, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12875.97 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13069.11, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 13519.77, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14163.57, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 12875.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 14163.57, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12875.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12875.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16738.76, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 12875.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12875.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12875.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMPUTATION OF LOWER LIMB EXCEPT TOES - SOI : 4", "code_information": [ { "code": "3054", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 31219.94, "maximum": 40585.92, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31219.94 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31688.24, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 32780.94, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34341.93, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 31219.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 34341.93, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31219.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 31219.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 40585.92, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 31219.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31219.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 31219.94, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS - SOI : 1", "code_information": [ { "code": "2341", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7065.57, "maximum": 9185.24, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7065.57 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7171.55, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7418.85, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7772.13, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 7772.13, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9185.24, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC", "code_information": [ { "code": "474", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 42350, "minimum": 42350.06, "maximum": 86233.9, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 42350.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 57172.58, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 43197.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 42350.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 42350.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 42350.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 42350.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 42350.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 42350.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 49690.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 42773.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 83646.88 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 42350.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 42350.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 68818.85, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 55055.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 42350.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 44891.11, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 42350.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 42350.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 50820.07, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 42350.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 42350.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 42350.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 74645.32 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 42350.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 42350.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 69048.1 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 84655.99 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 76190.39 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 42350.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 86233.9 } ] } ] }, { "description": "ANAL AND STOMAL PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "349", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8966, "minimum": 7650, "maximum": 17168.232, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 8966.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 12105.25, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9146.19, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8966.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 8966.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 8966.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 8966.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 8966.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8966.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 10077.2 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9056.52, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16430.25 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8966.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8966.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14571.13, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11656.91, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 8966.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9504.86, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8966.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 8966.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 10760.22, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8966.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8966.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8966.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 16928.26 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8966.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8966.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8833.9 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 17168.23 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 15451.41 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8966.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16938.4 } ] } ] }, { "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": 14309, "minimum": 14309.45, "maximum": 27968.876, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 14309.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 19317.76, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 14595.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 14309.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 14309.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 14309.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 14309.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 14309.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 14309.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 16416.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 14452.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23223.16 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 14309.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 14309.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 23252.86, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 18602.29, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 14309.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15168.07, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 14309.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 14309.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 17171.34, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 14309.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14309.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14309.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 20149.8 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14309.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14309.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16543.8 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 27968.88 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 25171.99 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 14309.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23941.4 } ] } ] }, { "description": "APPENDIX PROCEDURES WITH CC", "code_information": [ { "code": "398", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15239, "minimum": 13500, "maximum": 31305.3, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 15239.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 20572.74, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 15543.88, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 15239.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 15239.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 15239.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 15239.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 15239.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 15239.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 17519.92 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15391.49, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28223.61 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 15239.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 15239.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 24763.49, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 19810.79, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 15239.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16153.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 15239.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 13500, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 4500, "10th_percentile": 4500, "90th_percentile": 4500, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 15239.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 18286.88, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15239.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15239.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15239.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 26252.85 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15239.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15239.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 31305.3 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 29848.19 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 26863.37 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 15239.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29096.5 } ] } ] }, { "description": "Amputation Of Finger/Thumb - 26951 - OR36026951", "code_information": [ { "code": "26951", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14942, "discounted_cash": 4187, "minimum": 374.88, "maximum": 13447.8, "payers_information": [ { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 412.37 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 374.88 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "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": 393.62 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6281.57, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4229.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5351.14, "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": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5444.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 412.37 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 374.88 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 412.37 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 374.88 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4438.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 374.88 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 5025.25, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 487.34 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 374.88 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5351.18, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "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": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6281.57, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 374.88 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4271.46, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "ANES ADDL 15 MIN", "code_information": [ { "code": "Z7508", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2101.78, "minimum": 58.4661, "maximum": 1891.602, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 64.32 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 61.39 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 64.32 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 64.32 }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 76.01 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 } ] } ] }, { "description": "ANES 1ST 60 MIN", "code_information": [ { "code": "Z7506", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2828.16, "minimum": 146.1654, "maximum": 2545.344, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 146.17 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 160.79 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 146.17 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 153.48 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 160.79 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 146.17 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 160.79 }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 146.17 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 146.17 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 190.02 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 146.17 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 146.17 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 146.17 } ] } ] }, { "description": "AMPUTATION OF LOWER LIMB EXCEPT TOES - SOI : 2", "code_information": [ { "code": "3052", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12581.27, "maximum": 16355.65, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12581.27 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12769.99, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 13210.33, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13839.4, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 12581.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 13839.4, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12581.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12581.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16355.65, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 12581.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12581.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12581.27, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS - SOI : 2", "code_information": [ { "code": "1982", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4834.06, "maximum": 6284.28, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4834.06 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4906.57, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 5075.76, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5317.47, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4834.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 5317.47, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4834.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4834.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6284.28, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4834.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4834.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4834.06, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANTEPARTUM WITH O.R. PROCEDURE- SOI : 3", "code_information": [ { "code": "5473", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13219.02, "maximum": 17184.73, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13219.02 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13417.31, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 13879.97, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14540.92, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 13219.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 14540.92, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13219.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13219.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17184.73, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 13219.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13219.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13219.02, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 18718, "minimum": 18195.7, "maximum": 37141.7, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 18718.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 25270.03, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 19092.87, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 18718.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 18718.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 18718.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 18718.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 18718.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 18718.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 21648.72 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18905.69, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36027.45 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 18718.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 18718.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 30417.63, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 24334.1, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 18718.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19841.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 18718.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 18718.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 22462.25, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 18718.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18718.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18718.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 34427.27 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18718.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18718.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18195.7 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 36882.32 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 33194.08 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 18718.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37141.7 } ] } ] }, { "description": "ANTEPARTUM WITH O.R. PROCEDURE- SOI : 2", "code_information": [ { "code": "5472", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8566.24, "maximum": 11136.11, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8566.24 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8694.73, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 8994.55, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9422.86, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8566.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 9422.86, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8566.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8566.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11136.11, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 8566.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8566.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8566.24, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANTEPARTUM WITHOUT O.R. PROCEDURE- SOI : 1", "code_information": [ { "code": "5661", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2268.08, "maximum": 2948.5, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2268.08 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2302.1, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 2381.48, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2494.89, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 2268.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 2494.89, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2268.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 2268.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2948.5, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 2268.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2268.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 2268.08, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Artery-Vein Nonautograft", "code_information": [ { "code": "36830", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 42688, "discounted_cash": 7121, "minimum": 834.6774, "maximum": 38419.2, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10682.67, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 834.68 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7264.22, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 918.15 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 834.68 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "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": 876.41 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 10682.67, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7193, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9100.35, "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": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9258.31, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 918.15 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 834.68 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 918.15 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 834.68 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7549.09, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 834.68 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 8546.14, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1085.08 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 834.68 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 834.68 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9100.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 834.68 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9381.88, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "ANAL AND PERINEAL PROCEDURES- SOI : 4", "code_information": [ { "code": "2264", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 21704.49, "maximum": 28215.84, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21704.49 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22030.06, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 22789.71, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23874.94, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 23874.94, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28215.84, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANTEPARTUM WITH O.R. PROCEDURE- SOI : 4", "code_information": [ { "code": "5474", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 25639.21, "maximum": 33330.97, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25639.21 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26023.8, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 26921.17, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28203.13, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 25639.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 28203.13, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25639.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 25639.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33330.97, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 25639.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25639.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 25639.21, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS - SOI : 4", "code_information": [ { "code": "2334", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 24117.27, "maximum": 31352.45, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24117.27 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24479.03, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24117.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25323.13, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26529, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 24117.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 26529, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24117.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 24117.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31352.45, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 24117.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24117.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 24117.27, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Aspirate Pleura W/ Imaging", "code_information": [ { "code": "32555", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3152.55, "discounted_cash": 802, "minimum": 92.33, "maximum": 2837.295, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1204.29, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 92.33 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 818.92, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "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": 101.56 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 92.33 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "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": 96.95 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 1204.29, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 810.89, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1025.91, "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": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1043.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 101.56 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 92.33 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 101.56 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 132.44 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 851.03, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 92.33 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 963.43, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 120.03 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 92.33 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 92.33 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1025.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 92.33 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1057.65, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "ANAL AND STOMAL PROCEDURES WITH CC", "code_information": [ { "code": "348", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13241, "minimum": 13241.3, "maximum": 25809.536, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 13241.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 17875.78, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13506.13, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 13241.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 13241.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 13241.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 13241.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 13241.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 13241.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 15149.36 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13373.71, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23480.5 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 13241.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 13241.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21517.15, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 17213.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 13241.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14035.78, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13241.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 13241.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 15889.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13241.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13241.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13241.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 22576.79 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13241.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13241.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16085.4 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 25809.54 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 23228.58 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 13241.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24206.7 } ] } ] }, { "description": "ANTEPARTUM WITHOUT O.R. PROCEDURE- SOI : 2", "code_information": [ { "code": "5662", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3248.78, "maximum": 4223.41, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3248.78 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3297.51, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 3411.22, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3573.66, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3248.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 3573.66, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3248.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3248.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4223.41, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 3248.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3248.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3248.78, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS - SOI : 3", "code_information": [ { "code": "2343", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13392.24, "maximum": 17409.91, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13392.24 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13593.12, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 14061.85, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14731.46, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 13392.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 14731.46, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13392.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13392.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17409.91, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 13392.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13392.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13392.24, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ASTHMA - SOI : 2", "code_information": [ { "code": "1412", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4806.49, "maximum": 6248.44, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4806.49 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4878.59, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 5046.81, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5287.14, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4806.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 5287.14, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4806.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4806.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6248.44, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4806.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4806.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4806.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANAL AND STOMAL PROCEDURES WITH MCC", "code_information": [ { "code": "347", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 22867, "minimum": 22867.17, "maximum": 45509.9, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 22867.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 30870.68, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 23324.54, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 22867.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 22867.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 22867.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 22867.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 22867.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 22867.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 26571.57 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 23095.87, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 44144.6 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 22867.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 22867.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 37159.15, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 29727.32, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 22867.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 24239.23, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 22867.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 22867.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 27440.6, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 22867.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 22867.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 22867.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 44221.99 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 22867.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 22867.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 31446.5 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 45269.23 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 40742.31 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 22867.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 45509.9 } ] } ] }, { "description": "ANTEPARTUM WITHOUT O.R. PROCEDURE- SOI : 3", "code_information": [ { "code": "5663", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6022.96, "maximum": 7829.85, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6022.96 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6113.3, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 6324.11, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6625.26, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 6625.26, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7829.85, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ATHEROSCLEROSIS WITH MCC", "code_information": [ { "code": "302", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12146, "minimum": 12146.86, "maximum": 23596.952, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 12146.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 16398.26, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 12389.84, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 12146.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 12146.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 12146.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 12146.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 12146.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 12146.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 13850.65 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12268.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21697.45 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 12146.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 12146.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 19738.65, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 15790.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 12146.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12875.71, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 12146.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 12146.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 14576.23, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 12146.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12146.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12146.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 19448.93 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12146.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12146.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15456.9 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 23596.95 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 21237.26 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 12146.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22368.5 } ] } ] }, { "description": "ANGINA PECTORIS", "code_information": [ { "code": "311", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7321, "minimum": 7321.25, "maximum": 13841.468, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 7321.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 9883.69, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7467.68, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7321.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 7321.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 7321.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 7321.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 7321.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 7321.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8124.49 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7394.46, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13024.38 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7321.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7321.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11897.03, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9517.63, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 7321.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7760.53, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7321.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 7321.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 8785.5, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7321.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7321.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7321.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12110.7 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7321.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7321.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7902.64 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 13841.47 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 12457.32 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 7321.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13427.2 } ] } ] }, { "description": "APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS - SOI : 2", "code_information": [ { "code": "2332", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11244.48, "maximum": 14617.82, "payers_information": [ { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11244.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11244.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14617.82, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 11244.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11244.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11244.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11244.48 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11413.15, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 11806.7, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12368.93, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 11244.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 12368.93, "additional_payer_notes": "110% of State Medicaid Rates" } ] } ] }, { "description": "ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS - SOI : 1", "code_information": [ { "code": "1981", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3984.92, "maximum": 5180.4, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3984.92 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4044.69, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4184.17, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4383.41, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3984.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4383.41, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3984.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3984.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5180.4, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 3984.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3984.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3984.92, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS - SOI : 4", "code_information": [ { "code": "2344", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 21609.08, "maximum": 28091.8, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21609.08 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21933.22, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 22689.53, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23769.99, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 21609.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 23769.99, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21609.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 21609.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28091.8, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 21609.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21609.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 21609.08, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS - SOI : 4", "code_information": [ { "code": "1984", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10894.65, "maximum": 14163.05, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10894.65 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11058.07, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 11439.38, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11984.11, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 10894.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 11984.11, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10894.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10894.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14163.05, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 10894.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10894.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10894.65, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 84640.61, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 65108.16 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66084.78, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 68363.57, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 71618.98, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 65108.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 71618.98, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 65108.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 65108.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 84640.61, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 65108.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 65108.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 65108.16, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANOXIC & OTHER SEVERE BRAIN DAMAGE - SOI : 1", "code_information": [ { "code": "0591", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4225.56, "maximum": 5493.23, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4225.56 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4288.94, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4436.84, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4648.12, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4225.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4648.12, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4225.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4225.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5493.23, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4225.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4225.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4225.56, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Artery-Vein Autograft", "code_information": [ { "code": "36825", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50588, "discounted_cash": 7121, "minimum": 886.4879, "maximum": 45529.2, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10682.67, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 886.49 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7264.22, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 975.14 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 886.49 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "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": 930.81 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 10682.67, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7193, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9100.35, "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": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9258.31, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 975.14 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 886.49 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 975.14 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 886.49 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7549.09, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 886.49 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 8546.14, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1152.44 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 886.49 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 886.49 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9100.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 886.49 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9381.88, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "ANOXIC & OTHER SEVERE BRAIN DAMAGE - SOI : 3", "code_information": [ { "code": "0593", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10738.81, "maximum": 13960.45, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10738.81 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10899.89, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 11275.75, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11812.69, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 10738.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 11812.69, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10738.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10738.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13960.45, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 10738.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10738.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10738.81, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ARTHROSCOPY", "code_information": [ { "code": "509", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18000, "maximum": 33778.6, "payers_information": [ { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32765.24 }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 23699.21 }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23340.4 }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33778.6 } ] } ] }, { "description": "ANTEPARTUM WITH O.R. PROCEDURE- SOI : 1", "code_information": [ { "code": "5471", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4360.09, "maximum": 5668.12, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4360.09 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4425.49, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4578.09, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4796.1, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4360.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4796.1, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4360.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4360.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5668.12, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4360.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4360.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4360.09, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANTEPARTUM WITHOUT O.R. PROCEDURE- SOI : 4", "code_information": [ { "code": "5664", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13254.22, "maximum": 17230.49, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13254.22 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13453.03, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 13916.93, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14579.64, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 13254.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 14579.64, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13254.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13254.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17230.49, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 13254.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13254.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13254.22, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ASTHMA - SOI : 3", "code_information": [ { "code": "1413", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6672.27, "maximum": 8673.95, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6672.27 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6772.35, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7005.88, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7339.5, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6672.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 7339.5, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6672.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6672.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8673.95, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 6672.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6672.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6672.27, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC", "code_information": [ { "code": "268", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 67565, "minimum": 18061.6, "maximum": 135632.188, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 67565.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 91213.72, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 68917.01, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 67565.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 67565.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 67565.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 67565.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 67565.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 67565.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 79611.69 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 68241.36, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 124361.47 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 67565.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 67565.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 109794.3, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 87835.44, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 67565.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 71619.64, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 67565.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 67565.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 81078.86, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 67565.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 67565.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 67565.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 118915.89 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 67565.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 67565.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18061.6 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 135632.19 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 122068.97 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 67565.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 128207.7 } ] } ] }, { "description": "ATHEROSCLEROSIS WITHOUT MCC", "code_information": [ { "code": "303", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7041, "minimum": 6236.4, "maximum": 13275.504, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 7041.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 9505.74, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7182.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7041.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 7041.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 7041.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 7041.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 7041.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 7041.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 7792.29 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7111.7, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12541.32 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7041.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7041.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11442.1, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9153.68, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 7041.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7463.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7041.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 7041.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 8449.55, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7041.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7041.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7041.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 11416.77 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7041.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7041.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6236.4 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 13275.5 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 11947.95 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 7041.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12929.2 } ] } ] }, { "description": "AUTOLOGOUS BONE MARROW TRANSPLANT WITH CCMCC", "code_information": [ { "code": "016", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 58316, "minimum": 58316.4, "maximum": 116933.684, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 58316.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 78727.14, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 59482.73, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 58316.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 58316.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 58316.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 58316.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 58316.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 58316.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 68636.28 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 58899.56, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 112579.27 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 58316.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 58316.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 94764.15, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 75811.32, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 58316.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 61815.38, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 58316.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 58316.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 69979.68, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 58316.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 58316.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 58316.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 107159.1 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 58316.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 58316.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 60124.4 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 116933.68 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 105240.32 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 58316.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 116061.1 } ] } ] }, { "description": "BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC", "code_information": [ { "code": "519", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19985, "minimum": 14400, "maximum": 39443.944, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 19985.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 26980.64, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 20385.41, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 19985.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 19985.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 19985.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 19985.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 19985.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 19985.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 23152.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 20185.56, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36779.1 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 19985.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 19985.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 32476.7, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 25981.36, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 19985.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21184.84, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 19985.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 19985.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 23982.79, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 19985.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19985.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19985.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 34151.43 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19985.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19985.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 26675.3 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 39443.94 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 35499.55 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 19985.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37916.6 } ] } ] }, { "description": "APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS - SOI : 3", "code_information": [ { "code": "2333", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15997.97, "maximum": 20797.36, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15997.97 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16237.94, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 16797.87, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17597.77, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 15997.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 17597.77, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15997.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15997.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20797.36, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 15997.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15997.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15997.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CCMCC", "code_information": [ { "code": "017", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 53464, "minimum": 53464.46, "maximum": 116061.1, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 53464.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 72177.02, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 54533.79, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 53464.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 53464.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 53464.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 53464.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 53464.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 53464.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 62878.87 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 53999.15, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 112579.27 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 53464.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 53464.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 86879.75, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 69503.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 53464.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 56672.37, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 53464.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 53464.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 64157.35, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 53464.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 53464.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 53464.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 107159.1 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 53464.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 53464.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 80197 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 107124.96 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 96412.46 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 53464.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 116061.1 } ] } ] }, { "description": "BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM - SOI : 3", "code_information": [ { "code": "0493", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15618.45, "maximum": 20303.99, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15618.45 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15852.73, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 16399.37, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17180.3, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 15618.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 17180.3, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15618.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15618.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20303.99, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 15618.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15618.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15618.45, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS - SOI : 2", "code_information": [ { "code": "2342", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9012.97, "maximum": 11716.86, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9012.97 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9148.16, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 9463.62, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9914.27, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 9012.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 9914.27, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9012.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9012.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11716.86, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 9012.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9012.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9012.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Av Fistula Revision Open", "code_information": [ { "code": "36832", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 61688, "discounted_cash": 7121, "minimum": 886.4879, "maximum": 55519.2, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10682.67, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 886.49 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7264.22, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 975.14 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 886.49 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "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": 930.81 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 10682.67, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7193, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9100.35, "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": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9258.31, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 975.14 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 886.49 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 975.14 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 886.49 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7549.09, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 886.49 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 8546.14, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1152.44 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 886.49 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 886.49 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9100.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 886.49 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9381.88, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CCMCC", "code_information": [ { "code": "096", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 25633, "minimum": 23314.1, "maximum": 50861.824, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 25633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 34605.33, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 26146.27, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 25633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 25633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 25633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 25633.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 25633.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 25633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 29854.24 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 25889.94, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 44711.67 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 25633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 25633.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 41654.57, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 33323.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 25633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 27171.62, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 25633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 25633.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 30760.3, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 25633.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 25633.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 25633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 37813.61 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 25633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 25633.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23314.1 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 50861.82 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 45775.64 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 25633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 46094.5 } ] } ] }, { "description": "APPENDIX PROCEDURES WITH MCC", "code_information": [ { "code": "397", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 23835, "minimum": 22950, "maximum": 47644.3, "payers_information": [ { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 23835.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 23835.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 34814.9 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 47227.43 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 42504.69 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 23835.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 47644.3 }, { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 23835.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 32178.34, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 24312.52, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 23835.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 23835.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 23835.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 23835.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 23835.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 23835.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 27720.97 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 24074.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 46214.97 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 23835.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 23835.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 38733.19, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 30986.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 23835.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25265.95, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 23835.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 23835.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 28602.97, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 23835.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 23835.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 23835.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 38974.2 } ] } ] }, { "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": 44931.17, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34562.44 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35080.88, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 36290.56, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38018.68, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 34562.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 38018.68, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34562.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 34562.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44931.17, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 34562.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34562.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 34562.44, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BEHAVIORAL DISORDERS - SOI : 1", "code_information": [ { "code": "7581", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3371.12, "maximum": 4382.46, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3371.12 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3421.69, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 3539.68, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3708.23, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 3708.23, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4382.46, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "APPENDIX PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "399", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11640, "minimum": 8550, "maximum": 22573.484, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 11640.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 15714.8, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11873.41, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11640.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 11640.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 11640.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 11640.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 11640.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 11640.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 13249.9 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11757.01, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20960.63 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11640.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 11640.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18915.96, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 15132.77, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 11640.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12339.04, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11640.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 8550, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 9000, "10th_percentile": 9000, "90th_percentile": 9000, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 11640.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 13968.71, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11640.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11640.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11640.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 19310.15 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11640.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11640.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20136 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 22573.48 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 20316.14 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 11640.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21608.9 } ] } ] }, { "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": 55516.59, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42705.07 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 43345.65, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 44840.32, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 46975.58, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 42705.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 46975.58, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42705.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 42705.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55516.59, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 42705.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42705.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 42705.07, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Apply Hand/Wrist Cast", "code_information": [ { "code": "29085", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 668.7, "discounted_cash": 207, "minimum": 119.629, "maximum": 601.83, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 311.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 119.63 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 212.14, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 131.59 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 119.63 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "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": 125.61 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 311.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 210.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "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": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 270.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 131.59 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 119.63 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 131.59 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 119.63 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 220.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 119.63 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 249.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 155.52 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 119.63 }, { "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": 119.63 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 265.76, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 119.63 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Av Fuse Uppr Arm Basilic", "code_information": [ { "code": "36819", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 51288, "discounted_cash": 7121, "minimum": 780.21, "maximum": 46159.2, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10682.67, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 780.21 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7264.22, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 858.23 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 780.21 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "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": 819.22 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 10682.67, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7193, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9100.35, "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": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9258.31, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 858.23 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 780.21 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 858.23 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 780.21 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7549.09, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 780.21 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 8546.14, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1014.27 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 780.21 }, { "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": 780.21 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9100.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 780.21 }, { "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": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9381.88, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Arthrd Si Jt Perq/Min Nvas", "code_information": [ { "code": "27279", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 47888, "discounted_cash": 22440, "minimum": 486.6, "maximum": 43099.2, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22440.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 33661.37, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 486.6 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22889.73, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 22440.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22440.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 22440.91, "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": 535.33 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 486.6 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22440.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 22440.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 22440.91, "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": 510.93 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22440.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 33661.37, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22665.32, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28675.44, "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": 22440.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 22440.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 29173.18, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 535.26 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 486.6 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 535.26 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 22440.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 698.07 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23787.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 486.6 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22440.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 22440.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 26929.09, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 22440.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 632.58 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 486.6 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22440.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 486.6 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22440.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28675.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22440.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 486.6 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22440.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 22440.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22440.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29562.53, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Av Fusion Direct Any Site", "code_information": [ { "code": "36821", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 51769.2, "discounted_cash": 4041, "minimum": 623.2, "maximum": 46592.28, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 623.2 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4121.96, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 685.52 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 623.2 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "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": 654.36 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.85, "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": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5253.48, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 685.52 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 623.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 685.52 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 623.2 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4283.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 623.2 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 4849.37, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 810.16 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 623.2 }, { "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": 623.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 623.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC", "code_information": [ { "code": "462", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 26421, "minimum": 9900, "maximum": 55066.5, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 26421.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 35669.36, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 26950.24, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 26421.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 26421.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 26421.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 26421.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 26421.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 26421.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 30789.5 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 26686.02, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 53414.51 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 26421.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 26421.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 42935.34, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 34348.28, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 26421.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 28007.11, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 26421.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 26421.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 31706.1, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 26421.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 26421.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 26421.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 49377.84 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 26421.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 26421.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 28444.5 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 52455.2 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 47209.68 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 26421.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 55066.5 } ] } ] }, { "description": "ASTHMA - SOI : 1", "code_information": [ { "code": "1411", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3243.91, "maximum": 4217.08, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3243.91 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3292.57, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 3406.11, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3568.3, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3243.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 3568.3, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3243.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3243.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4217.08, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 3243.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3243.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3243.91, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BIOPSYREMOVAL LYMPH NODES", "code_information": [ { "code": "38525", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8111.02, "discounted_cash": 5011, "minimum": 212, "maximum": 7516.83, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7516.83, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 212 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5111.44, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 233.2 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 212 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 222.6 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 7516.83, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5061.33, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6403.44, "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": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6514.59, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 233.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 212 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 233.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 212 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5311.89, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 212 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 6013.46, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 275.6 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 212 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 212 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6403.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 212 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6601.53, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "ASTHMA - SOI : 4", "code_information": [ { "code": "1414", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11195.72, "maximum": 14554.44, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11195.72 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11363.66, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 11755.51, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12315.29, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 11195.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 12315.29, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11195.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11195.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14554.44, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 11195.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11195.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11195.72, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR", "code_information": [ { "code": "518", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 36930, "minimum": 24300, "maximum": 73699.556, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 36930.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 49856.03, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 37669.01, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 36930.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 36930.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 36930.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 36930.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 36930.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 36930.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 43259.25 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 37299.7, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 66847.36 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 36930.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 36930.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 60011.88, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 48009.51, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 36930.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 39146.22, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 36930.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 36930.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 44316.47, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 36930.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 36930.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 36930.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 63351.72 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 36930.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 36930.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 39444.9 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 73699.56 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 66329.6 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 36930.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 68914.8 } ] } ] }, { "description": "BIPOLAR DISORDERS - SOI : 2", "code_information": [ { "code": "7532", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4274.32, "maximum": 5556.62, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4274.32 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4338.43, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4488.04, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4701.75, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4274.32, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4701.75, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4274.32, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4274.32, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5556.62, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4274.32, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4274.32, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4274.32, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CCMCC", "code_information": [ { "code": "520", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15046, "minimum": 9000, "maximum": 29459.708, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 15046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 20313.32, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 15347.84, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 15046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 15046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 15046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 15046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 15046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 15046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 17291.89 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15197.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26731.45 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 15046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 15046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 24451.21, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 19560.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 15046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15949.71, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 15046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 9000, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 9000, "10th_percentile": 9000, "90th_percentile": 9000, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 15046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 18056.28, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 24833.78 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20898.5 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 29459.71 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 26513.74 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 15046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27558.2 } ] } ] }, { "description": "BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM - SOI : 1", "code_information": [ { "code": "0491", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8313.3, "maximum": 10807.29, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8313.3 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8438, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 8728.97, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9144.63, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8313.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 9144.63, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8313.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8313.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10807.29, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 8313.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8313.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8313.3, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BIPOLAR DISORDERS - SOI : 3", "code_information": [ { "code": "7533", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7316.81, "maximum": 9511.85, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7426.56, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7682.65, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8048.49, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 8048.49, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9511.85, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 37926.14, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29173.95 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29611.56, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 30632.65, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32091.35, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 29173.95, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 32091.35, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29173.95, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 29173.95, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 37926.14, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 29173.95, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29173.95, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 29173.95, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM - SOI : 4", "code_information": [ { "code": "0494", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 25716.97, "maximum": 33432.06, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27002.82, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28288.67, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 25716.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 28288.67, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25716.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 25716.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33432.06, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 25716.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25716.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 25716.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25716.97 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26102.72, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 25633, "minimum": 24750, "maximum": 50861.824, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 25633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 34605.33, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 26146.27, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 25633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 25633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 25633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 25633.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 25633.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 25633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 29854.24 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 25889.94, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 44711.67 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 25633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 25633.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 41654.57, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 33323.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 25633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 27171.62, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 25633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 25633.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 30760.3, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 25633.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 25633.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 25633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 41361.3 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 25633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 25633.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 30488.9 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 50861.82 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 45775.64 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 25633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 46094.5 } ] } ] }, { "description": "BONE DISEASES AND ARTHROPATHIES WITHOUT MCC", "code_information": [ { "code": "554", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8571, "minimum": 6657.75, "maximum": 16369.572, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 8571.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 11571.92, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8743.23, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8571.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 8571.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 8571.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 8571.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 8571.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8571.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 9608.41 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8657.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15566.66 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8571.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8571.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13929.16, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11143.33, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 8571.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9086.1, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8571.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 8571.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 10286.15, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8571.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8571.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8571.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 14256.65 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8571.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8571.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6657.75 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 16369.57 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 14732.61 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8571.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16048.1 } ] } ] }, { "description": "BEHAVIORAL DISORDERS - SOI : 4", "code_information": [ { "code": "7584", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 22778.37, "maximum": 29611.88, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22778.37 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23120.05, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 23917.29, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25056.21, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 22778.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 25056.21, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22778.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 22778.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29611.88, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 22778.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22778.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 22778.37, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 9810.91, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7546.85 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7660.05, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7924.19, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8301.54, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 7546.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 8301.54, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7546.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7546.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9810.91, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 7546.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7546.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7546.85, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC", "code_information": [ { "code": "461", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 54349, "minimum": 31950, "maximum": 118287.89, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 54349.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 73371.42, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 55436.18, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 54349.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 54349.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 54349.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 54349.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 54349.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 54349.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 63928.73 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 54892.69, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 114459.32 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 54349.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 54349.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 88317.45, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 70653.96, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 54349.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 57610.15, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 54349.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 54349.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 65219.04, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 54349.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 54349.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 54349.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 118287.89 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 54349.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 54349.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 81536.5 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 108913.56 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 98022.2 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 54349.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 117999.3 } ] } ] }, { "description": "BENIGN PROSTATIC HYPERTROPHY WITH MCC", "code_information": [ { "code": "725", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11889, "minimum": 11889.3, "maximum": 24277.9, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 11889.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 16050.6, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 12127.09, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11889.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 11889.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 11889.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 11889.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 11889.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 11889.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 13545.07 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12008.19, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23549.56 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11889.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 11889.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 19320.16, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 15456.13, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 11889.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12602.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11889.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 11889.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 14267.2, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11889.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11889.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11889.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 21527.23 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11889.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11889.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16776 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 23076.34 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 20768.71 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 11889.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24277.9 } ] } ] }, { "description": "BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "585", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19292, "minimum": 9900, "maximum": 38170.4, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 19292.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 26044.35, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 19677.94, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 19292.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 19292.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 19292.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 19292.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 19292.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 19292.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 22329.33 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 19485.02, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37025.29 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 19292.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 19292.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 31349.68, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 25079.74, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 19292.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20449.63, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 19292.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 19292.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 23150.53, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 19292.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19292.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19292.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 29214.17 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19292.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19292.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 36207 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 38041.85 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 34237.67 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 19292.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38170.4 } ] } ] }, { "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": 35255, "minimum": 33750, "maximum": 70313.632, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 35255.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 47594.97, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 35960.61, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 35255.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 35255.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 35255.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 35255.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 35255.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 35255.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 41271.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 35608.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 65304.86 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 35255.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 35255.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 57290.24, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 45832.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 35255.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 37370.83, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 35255.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 35255.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 42306.64, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 35255.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 35255.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 35255.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 64573.03 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 35255.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 35255.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 69814.2 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 70313.63 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 63282.27 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 35255.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 67324.6 } ] } ] }, { "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": 15961, "minimum": 14850, "maximum": 31309.444, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 15961.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 21548.54, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 16281.14, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 15961.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 15961.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 15961.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 15961.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 15961.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 15961.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 18377.63 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16121.52, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28930.54 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 15961.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 15961.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 25938.06, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 20750.44, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 15961.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16919.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 15961.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 15961.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 19154.26, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15961.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15961.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15961.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 27153.22 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15961.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15961.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24812.7 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 31309.44 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 28178.5 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 15961.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29825.3 } ] } ] }, { "description": "BRONCHITIS AND ASTHMA WITH CCMCC", "code_information": [ { "code": "202", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9948, "minimum": 8756.1, "maximum": 19152.064, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 9948.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 13430.03, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10147.13, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9948.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 9948.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 9948.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 9948.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 9948.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 9948.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 11241.64 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10047.65, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18030.55 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9948.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9948.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16165.78, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12932.62, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 9948.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10545.06, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9948.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 9948.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 11937.8, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9948.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9948.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9948.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 16610.79 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9948.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9948.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8756.1 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 19152.06 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 17236.86 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 9948.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18588.2 } ] } ] }, { "description": "BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM - SOI : 2", "code_information": [ { "code": "0492", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11038.82, "maximum": 14350.47, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11038.82 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11204.4, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 11590.76, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12142.7, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 11038.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 12142.7, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11038.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11038.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14350.47, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 11038.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11038.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11038.82, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BIOPSY OF CERVIX", "code_information": [ { "code": "57500", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12980.7, "discounted_cash": 1178, "minimum": 58.15, "maximum": 11682.603, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1768.23, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.15 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1202.4, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.97 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.15 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 61.06 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 1768.23, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.61, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1506.32, "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": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1532.47, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.97 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 58.15 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 63.97 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.15 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1249.55, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 58.15 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 1414.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 75.6 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 58.15 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.15 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1506.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 58.15 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1552.92, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 12980.67, "discounted_cash": 1178, "minimum": 58.15, "maximum": 11682.603, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1768.23, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.15 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1202.4, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.97 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.15 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 61.06 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 1768.23, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.61, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1506.32, "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": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1532.47, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.97 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 58.15 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 63.97 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.15 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1249.55, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 58.15 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 1414.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 75.6 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 58.15 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.15 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1506.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 58.15 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1552.92, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CCMCC", "code_information": [ { "code": "479", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18607, "minimum": 14850, "maximum": 36657.508, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 18607.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 25119.9, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 18979.45, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 18607.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 18607.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 18607.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 18607.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 18607.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 18607.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 21516.77 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18793.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33121.52 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 18607.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 18607.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 30236.91, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 24189.53, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 18607.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19723.74, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 18607.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 18607.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 22328.8, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 18607.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18607.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18607.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 32336.82 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18607.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18607.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20047.5 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 36657.51 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 32991.76 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 18607.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34145.9 } ] } ] }, { "description": "BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC", "code_information": [ { "code": "094", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 34804, "minimum": 34804.86, "maximum": 70158.9, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 34804.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 46986.56, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 35501, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 34804.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 34804.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 34804.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 34804.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 34804.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 34804.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 40737.06 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 35152.95, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 68054.13 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 34804.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 34804.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 56557.9, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 45246.32, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 34804.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 36893.19, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 34804.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 34804.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 41765.83, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 34804.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 34804.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 34804.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 62846.89 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 34804.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 34804.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 39498.8 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 69402.57 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 62462.31 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 34804.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 70158.9 } ] } ] }, { "description": "BIPOLAR DISORDERS - SOI : 4", "code_information": [ { "code": "7534", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13656.21, "maximum": 17753.07, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13656.21 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13861.05, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 14339.02, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15021.83, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 13656.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 15021.83, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13656.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13656.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17753.07, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 13656.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13656.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13656.21, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BEHAVIORAL AND DEVELOPMENTAL DISORDERS", "code_information": [ { "code": "886", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20718, "minimum": 5520, "maximum": 40924.916, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 20718.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 27969.61, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 21132.56, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 20718.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 20718.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 20718.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 20718.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 20718.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 20718.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 24021.6 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 20925.38, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33507.58 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 20718.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 20718.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 33667.12, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 26933.7, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 20718.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21961.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 20718.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 20718.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 24861.88, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 20718.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20718.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20718.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 29174.27 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 20718.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20718.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14695.7 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 40924.92 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 36832.42 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 20718.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34543.9 } ] } ] }, { "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": 14287.08, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10990.06 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11154.91, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 11539.56, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12089.07, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 10990.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 12089.07, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10990.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10990.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14287.08, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 10990.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10990.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10990.06, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BONE DISEASES AND ARTHROPATHIES WITH MCC", "code_information": [ { "code": "553", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13119, "minimum": 13119.39, "maximum": 25563.036, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 13119.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 17711.18, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13381.79, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 13119.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 13119.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 13119.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 13119.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 13119.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 13119.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 15004.67 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13250.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24359.03 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 13119.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 13119.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21319.01, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 17055.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 13119.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13906.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13119.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 13119.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 15743.27, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13119.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13119.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13119.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 23445.93 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13119.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13119.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17353 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 25563.04 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 23006.73 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 13119.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25112.4 } ] } ] }, { "description": "BEHAVIORAL DISORDERS - SOI : 2", "code_information": [ { "code": "7582", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4174.67, "maximum": 5427.07, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4174.67 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4237.29, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4383.4, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4592.14, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4174.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4592.14, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4174.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4174.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5427.07, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4174.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4174.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4174.67, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 6317.35, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4859.5 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4932.39, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 5102.48, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5345.45, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4859.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 5345.45, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4859.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4859.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6317.35, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4859.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4859.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4859.5, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 4112.34, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3163.34 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3210.79, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 3321.51, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3479.67, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3163.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 3479.67, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3163.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3163.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4112.34, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 3163.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3163.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3163.34, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BEHAVIORAL DISORDERS - SOI : 3", "code_information": [ { "code": "7583", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6793.12, "maximum": 8831.06, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6793.12 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6895.02, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7132.78, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7472.43, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6793.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 7472.43, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6793.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6793.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8831.06, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 6793.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6793.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6793.12, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 13614.55, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10472.73 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10629.82, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 10996.37, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11520, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 10472.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 11520, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10472.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10472.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13614.55, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 10472.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10472.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10472.73, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 8742.85, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6725.27 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6826.15, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7061.53, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7397.8, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6725.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 7397.8, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6725.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6725.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8742.85, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 6725.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6725.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6725.27, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC", "code_information": [ { "code": "726", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7517, "minimum": 4663.53, "maximum": 14313.7, "payers_information": [ { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7517.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 7517.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 7517.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 7517.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 7517.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 7517.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8357.15 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7592.49, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13884.29 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7517.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7517.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12215.65, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9772.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 7517.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7968.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7517.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 7517.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 9020.78, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7517.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7517.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7517.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12679.71 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7517.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7517.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 4663.53 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 14237.84 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 12814.06 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 7517.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14313.7 }, { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 7517.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 10148.38, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7667.67, "additional_payer_notes": "102.00% of Medicare Rates" } ] } ] }, { "description": "BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CCMCC", "code_information": [ { "code": "584", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21356, "minimum": 15300, "maximum": 42214.604, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 21356.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 28830.84, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 21783.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 21356.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 21356.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 21356.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 21356.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 21356.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 21356.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 24778.6 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 21569.76, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38187.35 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 21356.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 21356.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 34703.79, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 27763.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 21356.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22637.57, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 21356.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 21356.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 25627.42, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 21356.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21356.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 21356.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 33977.95 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 21356.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21356.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 38277.9 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 42214.6 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 37993.14 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 21356.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39368.4 } ] } ] }, { "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": 23395.14, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17996.26 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18266.2, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 18896.07, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19795.89, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 17996.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 19795.89, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17996.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 17996.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23395.14, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 17996.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17996.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 17996.26, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BRONCHIOLITIS & RSV PNEUMONIA - SOI : 1", "code_information": [ { "code": "1381", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2414.91, "maximum": 3139.38, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2414.91 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2451.13, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 2535.66, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2656.4, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 2414.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 2656.4, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2414.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 2414.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3139.38, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 2414.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2414.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 2414.91, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BREAST PROCEDURES EXCEPT MASTECTOMY - SOI : 3", "code_information": [ { "code": "3633", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 22764.59, "maximum": 29593.97, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22764.59 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23106.06, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 23902.82, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25041.05, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 22764.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 25041.05, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22764.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 22764.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29593.97, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 22764.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22764.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 22764.59, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARREST, UNEXPLAINED WITHOUT CCMCC", "code_information": [ { "code": "298", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 4913, "minimum": 4913.81, "maximum": 8974.572, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 4913.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 6633.64, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 5012.09, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 4913.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 4913.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 4913.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 4913.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 4913.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 4913.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 5267.78 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 4962.95, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8238.4 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 4913.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4913.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 7984.94, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 6387.95, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 4913.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 5208.64, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 4913.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 4913.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 5896.57, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 4913.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 4913.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 4913.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 7627.95 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 4913.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 4913.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5868.92 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 8974.57 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 8077.11 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 4913.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8493.2 } ] } ] }, { "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": 21713, "minimum": 20700, "maximum": 42936.356, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 21713.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 29312.82, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 22147.46, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 21713.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 21713.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 21713.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 21713.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 21713.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 21713.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 25202.25 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 21930.33, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39103.13 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 21713.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 21713.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 35283.95, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 28227.16, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 21713.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 23015.99, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 21713.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 21713.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 26055.84, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 21713.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21713.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 21713.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 33955.4 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 21713.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21713.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 32430.5 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 42936.36 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 38642.72 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 21713.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40312.5 } ] } ] }, { "description": "BRONCHIOLITIS & RSV PNEUMONIA - SOI : 2", "code_information": [ { "code": "1382", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3832.26, "maximum": 4981.94, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3832.26 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3889.74, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4023.87, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4215.49, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3832.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4215.49, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3832.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3832.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4981.94, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 3832.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3832.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3832.26, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS - SOI : 2", "code_information": [ { "code": "2012", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5121.34, "maximum": 6657.74, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5121.34 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5198.16, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 5377.41, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5633.47, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 5633.47, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6657.74, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC", "code_information": [ { "code": "478", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 24463, "minimum": 23400, "maximum": 48495.424, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 24463, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 33025.09, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 24952.26, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 24463, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 24463, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 24463, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 24463.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 24463.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 24463, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 28465.24 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 24707.63, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 43618.67 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 24463, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 24463.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 39752.42, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 31801.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 24463, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25930.78, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 24463, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 24463.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 29355.64, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 24463.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 24463.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 24463, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 41352.62 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 24463, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 24463.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23858.7 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 48495.42 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 43645.88 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 24463, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 44967.7 } ] } ] }, { "description": "BRONCHITIS AND ASTHMA WITHOUT CCMCC", "code_information": [ { "code": "203", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7010, "minimum": 5659.44, "maximum": 13394.5, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 7010.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 9463.61, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7150.28, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7010.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 7010.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 7010.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 7010.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 7010.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 7010.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 7755.25 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7080.18, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12992.67 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7010.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7010.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11391.38, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9113.1, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 7010.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7430.68, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7010.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 7010.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 8412.1, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7010.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7010.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7010.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12055.18 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7010.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7010.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5659.44 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 13212.4 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 11891.16 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 7010.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13394.5 } ] } ] }, { "description": "CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS - SOI : 3", "code_information": [ { "code": "2013", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7540.49, "maximum": 9802.64, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7540.49 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7653.6, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7917.51, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8294.54, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 7540.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 8294.54, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7540.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7540.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9802.64, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 7540.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7540.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7540.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC", "code_information": [ { "code": "477", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 34172, "minimum": 34172.77, "maximum": 68124.712, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 34172.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 46133.24, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 34856.26, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 34172.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 34172.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 34172.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 34172.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 34172.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 34172.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 39987 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 34514.53, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 64142.9 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 34172.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 34172.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 55530.75, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 44424.6, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 34172.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 36223.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 34172.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 34172.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 41007.32, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 34172.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 34172.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 34172.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 58445.69 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 34172.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 34172.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 53470.3 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 68124.71 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 61312.24 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 34172.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 66126.7 } ] } ] }, { "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": 13405.07, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10311.59 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10466.26, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 10827.17, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11342.75, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 10311.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 11342.75, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10311.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10311.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13405.07, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 10311.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10311.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10311.59, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC", "code_information": [ { "code": "308", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12219, "minimum": 11480.5, "maximum": 23742.88, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 12219, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 16495.7, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 12463.38, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 12219, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 12219, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 12219, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 12219.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 12219.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 12219, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 13936.3 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12341.19, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22491.97 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 12219, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 12219.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 19855.94, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 15884.75, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 12219, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12952.14, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 12219, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 12219.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 14662.85, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 12219.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12219.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12219, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 20855.86 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12219, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12219.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11480.5 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 23742.88 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 21368.59 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 12219, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23187.6 } ] } ] }, { "description": "Biopsy Abdominal Mass", "code_information": [ { "code": "49180", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6863, "discounted_cash": 2113, "minimum": 358.3275, "maximum": 6176.7, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 358.33 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 394.16 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 358.33 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 376.25 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.08, "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": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 394.16 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 358.33 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 394.16 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 358.33 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 358.33 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 2536.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 465.83 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 358.33 }, { "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": 358.33 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 358.33 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "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": 120281.81, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 92524.47 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 93912.34, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 97150.69, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 101776.92, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 101776.92, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 120281.81, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS - SOI : 1", "code_information": [ { "code": "1921", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8493.52, "maximum": 11041.58, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8493.52 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8620.92, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 8918.2, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9342.87, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 9342.87, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11041.58, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Biopsy of breast open", "code_information": [ { "code": "19101", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 24000, "discounted_cash": 5011, "minimum": 295.31, "maximum": 21600, "payers_information": [ { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 7516.83, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5061.33, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6403.44, "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": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6514.59, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 324.84 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 295.31 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 324.84 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 295.31 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5311.89, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 295.31 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 6013.46, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 383.9 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 295.31 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 295.31 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6403.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 295.31 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6601.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7516.83, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 295.31 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5111.44, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 324.84 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 295.31 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 310.08 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 24000, "discounted_cash": 5011, "minimum": 295.31, "maximum": 21600, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7516.83, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 295.31 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5111.44, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 324.84 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 295.31 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 310.08 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 7516.83, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5061.33, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6403.44, "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": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6514.59, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 324.84 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 295.31 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 324.84 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 295.31 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5311.89, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 295.31 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 6013.46, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 383.9 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 295.31 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 295.31 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6403.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 295.31 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6601.53, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "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": 12662.26, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9740.2 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9886.3, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 10227.21, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10714.22, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 10714.22, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12662.26, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BIOPSY OF PROSTATE", "code_information": [ { "code": "55700", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6443.66, "discounted_cash": 2566, "minimum": 125.4957, "maximum": 5799.294, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2566.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3849.33, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2617.54, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2566.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2566.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 2566.22, "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": 138.05 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2566.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2566.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2566.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2566.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3849.33, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2591.88, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3279.17, "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": 2566.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2566.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3336.09, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2566.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 125.5 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2720.19, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2566.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2566.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 3079.46, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2566.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2566.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2566.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3279.19, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2566.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2566.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2566.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2566.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3380.61, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CARDIAC STRUCTURAL & VALVULAR DISORDERS - SOI : 2", "code_information": [ { "code": "2002", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5660.93, "maximum": 7359.21, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5660.93 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5745.84, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 5943.98, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6227.02, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 6227.02, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5660.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5660.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7359.21, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 5660.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5660.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5660.93, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BIPOLAR DISORDERS - SOI : 1", "code_information": [ { "code": "7531", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3406.1, "maximum": 4427.93, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3406.1 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3457.19, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 3576.41, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3746.71, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3406.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 3746.71, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3406.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3406.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4427.93, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 3406.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3406.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3406.1, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 41951.65, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32270.5 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32754.56, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 33884.03, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35497.55, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 32270.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 35497.55, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32270.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 32270.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 41951.65, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 32270.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32270.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 32270.5, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 49639, "minimum": 13950, "maximum": 99392.744, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 49639.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 67013.57, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 50632.49, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 49639.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 49639.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 49639.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 49639.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 49639.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 49639.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 58340.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 50136.1, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 85659.34 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 49639.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 49639.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 80664.48, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 64531.58, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 49639.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 52618.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 49639.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 49639.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 59567.62, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 49639.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 49639.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 49639.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 80644.29 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 49639.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 49639.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 52230.2 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 99392.74 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 89453.47 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 49639.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 88308.6 } ] } ] }, { "description": "CARDIOMYOPATHY - SOI : 2", "code_information": [ { "code": "2052", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5360.93, "maximum": 6969.21, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5360.93 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5441.34, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 5628.98, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5897.02, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 5360.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 5897.02, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5360.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5360.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6969.21, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 5360.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5360.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5360.93, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BXCURETT OF CERVIX WSCOPE", "code_information": [ { "code": "57454", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1950, "discounted_cash": 390, "minimum": 123.5592, "maximum": 1755, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 585.02, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 123.56 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 397.81, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "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": 135.92 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 123.56 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "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": 129.74 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 585.02, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 393.91, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 498.36, "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": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 507.01, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 135.92 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 123.56 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 135.92 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 123.56 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 413.41, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 123.56 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 468.01, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 160.63 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 123.56 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 123.56 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 498.37, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 123.56 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 513.78, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 1950, "discounted_cash": 390, "minimum": 123.5592, "maximum": 1755, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 585.02, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 123.56 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 397.81, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "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": 135.92 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 123.56 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "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": 129.74 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 585.02, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 393.91, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 498.36, "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": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 507.01, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 135.92 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 123.56 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 135.92 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 123.56 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 413.41, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 123.56 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 468.01, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 160.63 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 123.56 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 123.56 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 498.37, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 123.56 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 390.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 513.78, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CARDIAC ARREST & SHOCK - SOI : 2", "code_information": [ { "code": "1962", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4660.2, "maximum": 6058.26, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4660.2 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4730.1, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4893.21, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5126.22, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4660.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 5126.22, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4660.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4660.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6058.26, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4660.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4660.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4660.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIOMYOPATHY - SOI : 3", "code_information": [ { "code": "2053", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8170.19, "maximum": 10621.25, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8170.19 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8292.74, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 8578.7, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8987.21, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 8987.21, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10621.25, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 6074.8, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4672.92 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4743.01, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4906.57, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5140.21, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4672.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 5140.21, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4672.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4672.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6074.8, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4672.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4672.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4672.92, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARREST & SHOCK - SOI : 3", "code_information": [ { "code": "1963", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7462.04, "maximum": 9700.65, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7462.04 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7573.97, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7835.14, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8208.24, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 7462.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 8208.24, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7462.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7462.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9700.65, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 7462.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7462.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7462.04, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CAROTID ARTERY STENT PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "036", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19425, "minimum": 5400, "maximum": 38312.016, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 19425.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 26224.76, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 19814.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 19425.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 19425.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 19425.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 19425.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 19425.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 19425.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 22487.91 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 19620.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34190.27 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 19425.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 19425.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 31566.84, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 25253.48, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 19425.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20591.35, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 19425.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 19425.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 23310.9, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 19425.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19425.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19425.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 31368.8 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19425.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19425.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 26941 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 38312.02 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 34480.81 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 19425.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35247.7 } ] } ] }, { "description": "BREAST PROCEDURES EXCEPT MASTECTOMY - SOI : 1", "code_information": [ { "code": "3631", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9470.93, "maximum": 12312.21, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9470.93 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9612.99, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 9944.48, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10418.02, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 9470.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 10418.02, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9470.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9470.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12312.21, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 9470.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9470.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9470.93, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS - SOI : 4", "code_information": [ { "code": "2014", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13236.41, "maximum": 17207.33, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13236.41 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13434.96, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 13898.23, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14560.05, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 13236.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 14560.05, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13236.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13236.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17207.33, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 13236.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13236.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13236.41, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BREAST PROCEDURES EXCEPT MASTECTOMY - SOI : 2", "code_information": [ { "code": "3632", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16578.9, "maximum": 21552.57, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16578.9 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16827.58, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 17407.85, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18236.79, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 16578.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 18236.79, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16578.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16578.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21552.57, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 16578.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16578.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16578.9, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE- SOI : 2", "code_information": [ { "code": "1912", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9237.71, "maximum": 12009.02, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9237.71 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9376.28, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 9699.6, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10161.48, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 9237.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 10161.48, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9237.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9237.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12009.02, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 9237.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9237.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9237.71, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BREAST PROCEDURES EXCEPT MASTECTOMY - SOI : 4", "code_information": [ { "code": "3634", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 27154.46, "maximum": 35300.8, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27154.46 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27561.78, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 28512.18, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29869.91, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 27154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 29869.91, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 27154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35300.8, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 27154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 27154.46, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE- SOI : 3", "code_information": [ { "code": "1913", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12200.69, "maximum": 15860.9, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12200.69 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12383.7, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 12810.72, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13420.76, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 12200.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 13420.76, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12200.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12200.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15860.9, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 12200.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12200.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12200.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BRONCHIOLITIS & RSV PNEUMONIA - SOI : 3", "code_information": [ { "code": "1383", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6974.4, "maximum": 9066.72, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6974.4 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7079.02, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7323.12, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7671.84, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6974.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 7671.84, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6974.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6974.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9066.72, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 6974.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6974.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6974.4, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS - SOI : 3", "code_information": [ { "code": "1923", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15382.05, "maximum": 19996.67, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15382.05 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15612.78, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 16151.15, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16920.26, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 15382.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 16920.26, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15382.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15382.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19996.67, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 15382.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15382.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15382.05, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BRONCHIOLITIS & RSV PNEUMONIA - SOI : 4", "code_information": [ { "code": "1384", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13157.96, "maximum": 17105.35, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13157.96 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13355.33, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 13815.86, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14473.76, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 13157.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 14473.76, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13157.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13157.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17105.35, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 13157.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13157.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13157.96, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC", "code_information": [ { "code": "306", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15845, "minimum": 15845.8, "maximum": 31074.776, "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 15845.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 25749.43, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 20599.54, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 15845.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16796.55, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 15845.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 15845.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 19014.96, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15845.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15845.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15845.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 26660.53 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15845.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15845.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19895.4 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 31074.78 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 27967.3 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 15845.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28792.7 }, { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 15845.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 21391.83, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 16162.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 15845.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 15845.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 15845.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 15845.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 15845.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 15845.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 18239.89 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16004.26, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27928.92 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 15845.8, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "Bronchoscopy W/Biopsy(S)", "code_information": [ { "code": "31625", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14942, "discounted_cash": 2278, "minimum": 288.9, "maximum": 13447.8, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3417.03, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 288.9 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2323.58, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "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": 317.79 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 288.9 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 303.35 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3417.03, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2300.8, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2910.9, "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": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2961.43, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 317.79 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 288.9 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 317.79 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 288.9 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2414.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 288.9 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 2733.62, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 375.57 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 288.9 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 288.9 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2910.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 288.9 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3000.95, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CARDIAC DEFIBRILLATOR IMPLANT WITH MCC", "code_information": [ { "code": "276", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 59066, "minimum": 27900, "maximum": 119108.8, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 59066.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 79739.82, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 60247.83, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 59066.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 59066.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 59066.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 59066.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 59066.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 59066.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 69526.4 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 59657.17, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 115535.54 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 59066.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 59066.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 95983.11, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 76786.49, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 59066.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 62610.49, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 59066.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 27900, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 4500, "10th_percentile": 4500, "90th_percentile": 4500, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 59066.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 70879.84, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 59066.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 59066.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 59066.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 107735.06 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 59066.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 59066.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 45097.2 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 118450.15 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 106605.14 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 59066.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 119108.8 } ] } ] }, { "description": "CESAREAN DELIVERY - SOI : 4", "code_information": [ { "code": "5404", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 21052.9, "maximum": 27368.77, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21052.9 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21368.69, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 22105.55, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23158.19, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 23158.19, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21052.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 21052.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27368.77, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 21052.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21052.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 21052.9, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARREST & SHOCK - SOI : 1", "code_information": [ { "code": "1961", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3610.7, "maximum": 4693.91, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3610.7 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3664.86, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 3791.24, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3971.77, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3610.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 3971.77, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3610.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3610.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4693.91, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 3610.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3610.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3610.7, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC STRUCTURAL & VALVULAR DISORDERS - SOI : 4", "code_information": [ { "code": "2004", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15253.78, "maximum": 19829.91, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15253.78 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15482.59, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 16016.47, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16779.16, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 15253.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 16779.16, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15253.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15253.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19829.91, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 15253.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15253.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15253.78, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CESAREAN SECTION WITH STERILIZATION- SOI : 3", "code_information": [ { "code": "5393", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11858.17, "maximum": 15415.62, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11858.17 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12036.04, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 12451.08, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13043.99, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 13043.99, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11858.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11858.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15415.62, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 11858.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11858.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11858.17, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE- SOI : 1", "code_information": [ { "code": "1911", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7807.64, "maximum": 10149.93, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7807.64 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7924.75, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 8198.02, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8588.4, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 7807.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 8588.4, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7807.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7807.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10149.93, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 7807.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7807.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7807.64, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 64613, "minimum": 23400, "maximum": 129664.916, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 64614, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 87228.87, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 65906.28, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 64614, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 64614, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 64614, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 64613.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 64613.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 64614, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 76109.1 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 65260.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 120450.24 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 64614, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 64613.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 104997.72, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 83998.17, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 64614, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 68490.84, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 64614, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 64613.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 77536.78, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 64613.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 64613.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 64614, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 110425.74 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 64614, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 64613.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 62868 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 129664.92 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 116698.42 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 64614, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 124175.5 } ] } ] }, { "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": 47338, "minimum": 46800, "maximum": 96280.8, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 47338.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 63907.06, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 48285.37, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 47338.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 47338.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 47338.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 47338.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 47338.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 47338.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 55609.77 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 47811.99, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 93392.38 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 47338.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 47338.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 76925.16, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 61540.13, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 47338.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 50178.92, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 47338.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 47338.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 56806.27, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 47338.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 47338.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 47338.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 84034.11 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 47338.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 47338.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 60902.5 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 94740.8 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 85266.72 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 47338.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 96280.8 } ] } ] }, { "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": 32864.26, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25280.2 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25659.4, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 26544.21, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27808.22, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 25280.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 27808.22, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25280.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 25280.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32864.26, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 25280.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25280.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 25280.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 75373, "minimum": 38250, "maximum": 151416.076, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 75373.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 101753.97, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 76880.77, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 75373.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 75373.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 75373.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 75373.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 75373.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 75373.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 88876.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 76127.03, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 144316.79 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 75373.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 75373.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 122481.63, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 97985.3, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 75373.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 79895.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 75373.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 75373.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 90447.97, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 75373.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 75373.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 75373.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 133774.53 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 75373.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 75373.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 91055.1 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 151416.08 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 136274.47 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 75373.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 148780.2 } ] } ] }, { "description": "CHEST PAIN", "code_information": [ { "code": "313", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7497, "minimum": 7497.81, "maximum": 14198.4, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 7497.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 10122.04, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7647.77, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7497.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 7497.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 7497.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 7497.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 7497.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 7497.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8334 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7572.79, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13306.07 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7497.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7497.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12183.94, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9747.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 7497.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7947.68, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7497.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 7650, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 9000, "10th_percentile": 9000, "90th_percentile": 9000, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 7497.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 8997.37, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7497.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7497.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7497.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12553.07 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7497.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7497.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7845.18 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 14198.4 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 12778.56 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 7497.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13717.6 } ] } ] }, { "description": "CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC", "code_information": [ { "code": "277", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 45526, "minimum": 14850, "maximum": 91076.82, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 45526.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 61460.32, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 46436.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 45526.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 45526.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 45526.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 45526.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 45526.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 45526.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 53459.14 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 45981.46, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 86765.43 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 45526.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 45526.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 73980.01, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 59184.01, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 45526.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 48257.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 45526.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 45526.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 54631.39, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 45526.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 45526.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 45526.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 82965.46 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 45526.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 45526.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 64130.8 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 91076.82 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 81969.14 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 45526.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 89448.9 } ] } ] }, { "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": 49455.58, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38042.75 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38613.39, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 39944.89, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 41847.03, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 41847.03, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38042.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 38042.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 49455.58, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 38042.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38042.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 38042.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHEST PAIN - SOI : 3", "code_information": [ { "code": "2033", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6017.13, "maximum": 7822.27, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6017.13 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6107.39, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 6317.99, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6618.84, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 6618.84, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6017.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6017.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7822.27, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 6017.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6017.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6017.13, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT - SOI : 2", "code_information": [ { "code": "1772", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14638.92, "maximum": 19030.6, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14638.92 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14858.5, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 15370.87, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16102.81, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 14638.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 16102.81, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14638.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14638.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19030.6, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 14638.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14638.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14638.92, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX - SOI : 2", "code_information": [ { "code": "1622", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 44276.14, "maximum": 57558.98, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44276.14 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44940.28, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 46489.95, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48703.75, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 48703.75, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 57558.98, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES", "code_information": [ { "code": "018", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 421705, "minimum": 55350, "maximum": 851564.816, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 421706, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 569302.91, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 430140.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 421706, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 421706, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 421706, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 421705.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 421705.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 421706, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 499840.91 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 425923.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 703404.42 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 421706, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 421705.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 685272.02, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 548217.62, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 421706, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 447008.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 421706, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 421705.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 506047.03, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 421705.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 421705.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 421706, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 639150.16 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 421706, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 421705.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 434781 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 851564.82 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 766408.33 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 421706, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 725159.2 } ] } ] }, { "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": 21453.35, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16502.58 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16750.12, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 17327.71, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18152.84, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 16502.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 18152.84, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16502.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16502.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21453.35, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 16502.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16502.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16502.58, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT - SOI : 4", "code_information": [ { "code": "1774", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 28401.14, "maximum": 36921.48, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28401.14 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28827.16, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 29821.2, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31241.25, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 28401.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 31241.25, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28401.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 28401.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36921.48, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 28401.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28401.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 28401.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CAROTID ARTERY STENT PROCEDURES WITH MCC", "code_information": [ { "code": "034", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 38231, "minimum": 21150, "maximum": 76330.204, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 38231.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 51612.74, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 38996.33, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 38231.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 38231.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 38231.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 38231.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 38231.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 38231.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 44803.35 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 38614.02, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 72530.49 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 38231.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 38231.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 62126.45, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 49701.16, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 38231.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 40525.6, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 38231.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 38231.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 45877.99, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 38231.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 38231.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 38231.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 67681.8 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 38231.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 38231.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 51668.8 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 76330.2 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 68697.18 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 38231.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 74773.7 } ] } ] }, { "description": "CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC", "code_information": [ { "code": "258", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 31124, "minimum": 21600, "maximum": 61962.212, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 31124.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 42018.01, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 31746.99, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 31124.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 31124.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 31124.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 31124.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 31124.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 31124.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 36369.81 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 31435.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 52327.14 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 31124.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 31124.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 50577.23, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 40461.79, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 31124.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 32991.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 31124.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 31124.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 37349.34, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 31124.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 31124.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 31124.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 46989.01 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 31124.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 31124.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 37276 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 61962.21 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 55765.99 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 31124.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 53945.5 } ] } ] }, { "description": "CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC", "code_information": [ { "code": "261", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18915, "minimum": 13500, "maximum": 37280.66, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 18915.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 25536.03, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 19293.91, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 18915.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 18915.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 18915.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 18915.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 18915.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 18915.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 21882.54 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 19104.76, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35393.26 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 18915.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 18915.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 30737.82, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 24590.25, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 18915.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20050.54, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 18915.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 18915.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 22698.7, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 18915.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18915.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18915.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 32645.62 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18915.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18915.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 33206.2 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 37280.66 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 33552.59 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 18915.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36487.9 } ] } ] }, { "description": "CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC", "code_information": [ { "code": "260", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 32204, "minimum": 25650, "maximum": 70722.7, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 32204.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 43475.79, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 32848.39, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 32204.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 32204.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 32204.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 32204.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 32204.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 32204.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 37651.16 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 32526.34, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 63531.12 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 32204.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 32204.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 52331.97, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 41865.58, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 32204.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 34136.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 32204.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 32204.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 38645.15, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 32204.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 32204.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 32204.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 57512.36 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 32204.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 32204.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 70722.7 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 64145.22 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 57730.69 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 32204.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 65496 } ] } ] }, { "description": "CARDIAC ARREST & SHOCK - SOI : 4", "code_information": [ { "code": "1964", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14134.31, "maximum": 18374.6, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14134.31 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14346.32, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 14841.03, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15547.74, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 14134.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 15547.74, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14134.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14134.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18374.6, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 14134.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14134.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14134.31, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CCMCC", "code_information": [ { "code": "262", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16373, "minimum": 9000, "maximum": 32141.628, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 16373.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 22104.27, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 16700.97, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 16373.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 16373.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 16373.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 16373.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 16373.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 16373.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 18866.09 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16537.24, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28309.45 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 16373.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 16373.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 26606.99, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 21285.59, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 16373.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17355.91, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 16373.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 16373.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 19648.24, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 16373.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16373.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16373.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 28542.8 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16373.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16373.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20167.2 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 32141.63 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 28927.47 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 16373.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29185 } ] } ] }, { "description": "CARDIAC ARREST, UNEXPLAINED WITH CC", "code_information": [ { "code": "297", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6658, "minimum": 5850, "maximum": 13544.5, "payers_information": [ { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 6658.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 6658.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 6658.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 6658.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 7338.55 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6725.5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13138.17 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6658.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6658.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 10820.73, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 8656.58, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 6658.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7058.44, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6658.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 6658.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 7990.69, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6658.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6658.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6658.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12639.81 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6658.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6658.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9359.39 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 12502.48 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 11252.23 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 6658.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13544.5 }, { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 6658.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 8989.53, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6792.09, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6658.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 6658.91, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "CARDIAC STRUCTURAL & VALVULAR DISORDERS - SOI : 1", "code_information": [ { "code": "2001", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3867.24, "maximum": 5027.41, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3867.24 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3925.25, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4060.6, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4253.96, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3867.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4253.96, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3867.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3867.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5027.41, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 3867.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3867.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3867.24, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC", "code_information": [ { "code": "415", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20634, "minimum": 20250, "maximum": 40755.324, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 20634.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 27856.36, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 21046.99, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 20634.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 20634.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 20634.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 20634.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 20634.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 20634.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 23922.05 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 20840.64, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36894.73 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 20634.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 20634.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 33530.8, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 26824.64, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 20634.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21872.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 20634.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 20634.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 24761.21, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 20634.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20634.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20634.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 34276.34 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 20634.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20634.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 26875.2 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 40755.32 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 36679.79 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 20634.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38035.8 } ] } ] }, { "description": "CARDIAC ARREST, UNEXPLAINED WITH MCC", "code_information": [ { "code": "296", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15710, "minimum": 9000, "maximum": 31503.9, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 15710.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 21208.8, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 16024.4, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 15710.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 15710.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 15710.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 15710.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 15710.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 15710.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 18078.99 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15867.3, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30558.78 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 15710.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 15710.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 25529.11, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 20423.29, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 15710.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16652.81, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 15710.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 15710.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 18852.26, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15710.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15710.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15710.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 27812.44 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15710.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15710.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 27595.8 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 30800.67 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 27720.6 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 15710.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31503.9 } ] } ] }, { "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": 95901, "minimum": 48150, "maximum": 192916.816, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 95901.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 129467.55, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 97819.94, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 95901.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 95901.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 95901.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 95901.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 95901.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 95901.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 113235.91 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 96860.92, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 180008.53 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 95901.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 95901.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 155840.57, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 124672.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 95901.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 101656.01, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 95901.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 95901.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 115082.27, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 95901.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 95901.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 95901.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 168368.33 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 95901.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 95901.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 137385 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 192916.82 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 173625.13 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 95901.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 185575.8 } ] } ] }, { "description": "CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CCMCC", "code_information": [ { "code": "416", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13772, "minimum": 12600, "maximum": 27196, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 13773, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 18593.48, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 14048.46, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 13773, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 13773, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 13773, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 13772.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 13772.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 13773, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 15780.2 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13910.73, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25556.4 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 13773, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 13772.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 22381.04, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 17904.84, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 13773, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14599.38, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13773, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 13772.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 16527.54, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13772.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13772.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13773, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 23232.55 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13773, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13772.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 27196 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 26884.28 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 24195.85 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 13773, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26346.8 } ] } ] }, { "description": "CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS - SOI : 1", "code_information": [ { "code": "2011", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3796.22, "maximum": 4935.09, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3796.22 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3853.16, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 3986.03, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4175.84, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3796.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4175.84, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3796.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3796.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4935.09, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 3796.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3796.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3796.22, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 75210.07, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 57853.9 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 58721.71, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 60746.6, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 63639.29, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 57853.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 63639.29, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 57853.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 57853.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 75210.07, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 57853.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 57853.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 57853.9, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC", "code_information": [ { "code": "309", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7650, "minimum": 6354.91, "maximum": 14508.004, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 7650.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 10328.8, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7803.98, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7650.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 7650.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 7650.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 7650.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 7650.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 7650.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8515.73 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7727.47, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13789.13 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7650.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7650.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12432.81, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9946.25, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 7650.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8110.02, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7650.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 7650.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 9181.15, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7650.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7650.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7650.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12919.12 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7650.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7650.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6354.91 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 14508 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 13057.2 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 7650.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14215.6 } ] } ] }, { "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": 105002.48, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 80771.14 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 81982.71, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 84809.7, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 88848.25, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 80771.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 88848.25, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 80771.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 80771.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 105002.48, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 80771.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 80771.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 80771.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHRONIC KIDNEY DISEASE - SOI : 1", "code_information": [ { "code": "4701", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3852.4, "maximum": 5008.12, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3852.4 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3910.19, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4045.02, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4237.64, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4237.64, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3852.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3852.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5008.12, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 3852.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3852.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3852.4, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CCMCC", "code_information": [ { "code": "310", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 5996, "minimum": 5398.5, "maximum": 11163.492, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 5996.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 8095.37, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6116.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 5996.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 5996.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 5996.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 5996.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 5996.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 5996.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 6552.61 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6056.54, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10435.55 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 5996.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 5996.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 9744.43, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 7795.54, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 5996.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6356.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 5996.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 8100, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 4500, "10th_percentile": 4500, "90th_percentile": 27000, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 5996.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 7195.88, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 5996.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 5996.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 5996.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 9593.49 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 5996.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 5996.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5398.5 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 11163.49 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 10047.14 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 5996.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10758.3 } ] } ] }, { "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": 41518.92, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31937.63 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32416.69, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 33534.51, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35131.39, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 31937.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 35131.39, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31937.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 31937.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 41518.92, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 31937.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31937.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 31937.63, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHRONIC KIDNEY DISEASE - SOI : 4", "code_information": [ { "code": "4704", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14561.53, "maximum": 18929.99, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14561.53 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14779.95, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 15289.61, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16017.68, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 16017.68, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14561.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14561.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18929.99, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 14561.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14561.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14561.53, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE- SOI : 4", "code_information": [ { "code": "1914", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18727.73, "maximum": 24346.05, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18727.73 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19008.65, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 19664.12, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20600.5, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 18727.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 20600.5, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18727.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18727.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24346.05, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 18727.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18727.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18727.73, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 47958.92, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36891.48 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 37444.85, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 38736.05, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 40580.63, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 36891.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 40580.63, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36891.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 36891.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 47958.92, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 36891.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36891.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 36891.48, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE - SOI : 3", "code_information": [ { "code": "1403", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7406.92, "maximum": 9629, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7406.92 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7518.02, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7777.27, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8147.61, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 8147.61, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7406.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7406.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9629, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 7406.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7406.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7406.92, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS - SOI : 2", "code_information": [ { "code": "1922", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10796.06, "maximum": 14034.88, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10796.06 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10958, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 11335.86, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11875.67, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 10796.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 11875.67, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10796.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10796.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14034.88, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 10796.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10796.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10796.06, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIOMYOPATHY - SOI : 4", "code_information": [ { "code": "2054", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15093.7, "maximum": 19621.81, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15093.7 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15320.11, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 15848.39, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16603.07, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 15093.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 16603.07, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15093.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15093.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19621.81, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 15093.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15093.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15093.7, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC", "code_information": [ { "code": "191", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8697, "minimum": 8697.63, "maximum": 16623.96, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 8697.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 11741.8, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8871.58, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8697.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 8697.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 8697.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 8697.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 8697.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8697.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 9757.73 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8784.61, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16023.62 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8697.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8697.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14133.65, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11306.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 8697.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9219.49, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8697.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 12150, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 4500, "10th_percentile": 4500, "90th_percentile": 4500, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 8697.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 10437.16, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8697.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8697.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8697.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 14728.52 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8697.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8697.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9616.75 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 16623.96 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 14961.56 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8697.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16519.2 } ] } ] }, { "description": "CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC", "code_information": [ { "code": "307", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9382, "minimum": 9382.4, "maximum": 18008.304, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 9382.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 12666.24, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9570.05, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9382.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 9382.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 9382.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 9382.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 9382.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 9382.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 10570.29 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9476.22, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17278.8 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9382.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9382.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15246.4, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12197.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 9382.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9945.34, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9382.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 9382.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 11258.88, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9382.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9382.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9382.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 16352.3 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9382.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9382.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10609.1 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 18008.3 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 16207.47 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 9382.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17813.2 } ] } ] }, { "description": "CELLULITIS WITH MCC", "code_information": [ { "code": "602", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14338, "minimum": 14338.7, "maximum": 28250.5, "payers_information": [ { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 25805.27 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14338.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14338.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15192.4 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 28028.04 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 25225.23 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 14338.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28250.5 }, { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 14338.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 19357.27, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 14625.47, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 14338.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 14338.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 14338.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 14338.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 14338.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 14338.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 16451.55 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 14482.09, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27402.99 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 14338.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 14338.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 23300.42, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 18640.34, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 14338.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15199.02, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 14338.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 14338.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 17206.46, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 14338.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14338.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14338.7, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC", "code_information": [ { "code": "275", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 70028, "minimum": 37350, "maximum": 140611.488, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 70028.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 94538.83, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 71429.38, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 70028.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 70028.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 70028.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 70028.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 70028.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 70028.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 82534.38 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 70729.09, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 131810.97 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 70028.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 70028.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 113796.74, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 91037.39, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 70028.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 74230.53, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 70028.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 70028.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 84034.51, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 70028.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 70028.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 70028.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 122057.63 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 70028.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 70028.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 77949 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 140611.49 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 126550.34 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 70028.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 135887.6 } ] } ] }, { "description": "CERVICAL SPINAL FUSION WITH MCC", "code_information": [ { "code": "471", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 47576, "minimum": 31950, "maximum": 95221.964, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 47576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 64228.38, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 48528.13, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 47576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 47576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 47576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 47576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 47576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 47576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 55892.2 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 48052.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 90596.45 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 47576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 47576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 77311.94, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 61849.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 47576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 50431.2, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 47576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 47576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 57091.9, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 47576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 47576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 47576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 85335.21 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 47576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 47576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 52730.5 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 95221.96 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 85699.77 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 47576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 93398.4 } ] } ] }, { "description": "CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC", "code_information": [ { "code": "287", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10912, "minimum": 9450, "maximum": 21102.372, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 10912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 14732.42, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11131.16, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 10912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 10912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 10912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 10912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 10912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 10912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 12386.41 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11022.03, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20324.7 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 10912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 17733.46, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14186.77, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 10912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11567.67, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 10912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 13095.48, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 18763.68 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14508.9 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 21102.37 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 18992.13 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 10912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20953.3 } ] } ] }, { "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": 24064.91, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18511.47 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18789.14, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 19437.04, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20362.62, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 20362.62, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18511.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18511.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24064.91, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 18511.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18511.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18511.47, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CESAREAN DELIVERY - SOI : 2", "code_information": [ { "code": "5402", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6800.75, "maximum": 8840.98, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6800.75 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6902.76, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7140.79, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7480.83, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 7480.83, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6800.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6800.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8840.98, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 6800.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6800.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6800.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CLEFT LIP & PALATE REPAIR - SOI : 2", "code_information": [ { "code": "0952", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8045.1, "maximum": 10458.63, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8045.1 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8165.78, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 8447.36, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8849.61, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 8849.61, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8045.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8045.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10458.63, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 8045.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8045.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8045.1, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC", "code_information": [ { "code": "259", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20199, "minimum": 10800, "maximum": 39875.812, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 20199.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 27269.04, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 20603.29, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 20199.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 20199.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 20199.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 20199.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 20199.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 20199.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 23405.81 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 20401.29, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32783.96 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 20199.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 20199.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 32823.85, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 26259.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 20199.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21411.26, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 20199.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 20199.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 24239.15, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 20199.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20199.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20199.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 32381.93 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 20199.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20199.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23353.6 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 39875.81 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 35888.23 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 20199.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33797.9 } ] } ] }, { "description": "CESAREAN SECTION WITH STERILIZATION- SOI : 1", "code_information": [ { "code": "5391", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5511.04, "maximum": 7164.35, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5511.04 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5593.71, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 5786.59, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6062.14, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 6062.14, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5511.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5511.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7164.35, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 5511.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5511.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5511.04, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC STRUCTURAL & VALVULAR DISORDERS - SOI : 3", "code_information": [ { "code": "2003", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8622.85, "maximum": 11209.71, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8622.85 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8752.19, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 9053.99, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9485.14, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 9485.14, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8622.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8622.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11209.71, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 8622.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8622.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8622.85, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CESAREAN SECTION WITH STERILIZATION- SOI : 4", "code_information": [ { "code": "5394", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 24337.19, "maximum": 31638.35, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24337.19 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24702.25, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 25554.05, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26770.91, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 26770.91, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24337.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 24337.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31638.35, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 24337.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24337.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 24337.19, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 64613, "minimum": 10350, "maximum": 129664.916, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 64614, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 87228.87, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 65906.28, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 64614, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 64614, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 64614, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 64613.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 64613.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 64614, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 76109.1 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 65260.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 110964.02 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 64614, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 64613.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 104997.72, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 83998.17, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 64614, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 68490.84, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 64614, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 64613.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 77536.78, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 64613.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 64613.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 64614, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 98826.82 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 64614, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 64613.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 79046.7 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 129664.92 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 116698.42 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 64614, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 114395.9 } ] } ] }, { "description": "CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CCMCC", "code_information": [ { "code": "788", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9827, "minimum": 8000, "maximum": 17396, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 9827.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 13266.73, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10023.75, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9827.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 9827.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 9827.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 9827.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 9827.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 9827.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8000 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9925.48, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16874.12 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9827.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9827.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15969.22, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12775.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 9827.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10416.84, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9827.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 13050, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 13500, "10th_percentile": 9000, "90th_percentile": 22500, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 9827.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 11792.65, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9827.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9827.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9827.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 14832.61 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9827.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9827.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11892.3 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 11854 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 10669 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 9827.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17396 } ] } ] }, { "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": 52493, "minimum": 25200, "maximum": 105162.816, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 52493.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 70866.72, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 53543.78, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 52493.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 52493.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 52493.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 52493.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 52493.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 52493.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 61727.16 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 53018.84, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 98791.98 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 52493.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 52493.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 85302.54, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 68242.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 52493.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 55643.53, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 52493.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 52493.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 62992.64, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 52493.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 52493.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 52493.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 90983.75 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 52493.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 52493.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 62741.1 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 105162.82 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 94646.53 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 52493.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 101847.4 } ] } ] }, { "description": "CHEMOTHERAPY FOR ACUTE LEUKEMIA - SOI : 1", "code_information": [ { "code": "6951", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5846.45, "maximum": 7600.39, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5846.45 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5934.15, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 6138.77, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6431.1, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 6431.1, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5846.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5846.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7600.39, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 5846.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5846.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5846.45, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 63099.06, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48537.74 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 49265.81, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 50964.63, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 53391.51, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 48537.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 53391.51, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48537.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 48537.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 63099.06, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 48537.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48537.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 48537.74, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CELLULITIS & OTHER SKIN INFECTIONS - SOI : 1", "code_information": [ { "code": "3831", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3744.27, "maximum": 4867.55, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3744.27 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3800.43, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 3931.48, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4118.7, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3744.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4118.7, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3744.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3744.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4867.55, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 3744.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3744.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3744.27, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CCMCC", "code_information": [ { "code": "848", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8760, "minimum": 8723.78, "maximum": 16750.168, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 8760.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 11826.08, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8935.26, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8760.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 8760.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 8760.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 8760.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 8760.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8760.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 9831.81 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8847.66, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15273.81 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8760.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8760.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14235.1, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11388.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 8760.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9285.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8760.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 8760.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 10512.07, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8760.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8760.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8760.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 14506.47 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8760.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8760.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8723.78 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 16750.17 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 15075.15 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8760.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15746.2 } ] } ] }, { "description": "COCAINE ABUSE & DEPENDENCE - SOI : 4", "code_information": [ { "code": "7744", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15091.58, "maximum": 19619.05, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15091.58 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15317.95, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 15846.16, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16600.74, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 16600.74, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15091.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15091.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19619.05, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 15091.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15091.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15091.58, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 92307.15, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 71005.5 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 72070.58, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 74555.78, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 78106.05, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 78106.05, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 71005.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 71005.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 92307.15, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 71005.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 71005.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 71005.5, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CELLULITIS & OTHER SKIN INFECTIONS - SOI : 3", "code_information": [ { "code": "3833", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7731.31, "maximum": 10050.7, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7731.31 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7847.28, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 8117.88, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8504.44, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 7731.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 8504.44, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7731.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7731.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10050.7, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 7731.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7731.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7731.31, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHEST PAIN - SOI : 1", "code_information": [ { "code": "2031", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4004, "maximum": 5205.2, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4004 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4064.06, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4204.2, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4404.4, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4404.4, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4004, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4004, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5205.2, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4004, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4004, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4004, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIOMYOPATHY - SOI : 1", "code_information": [ { "code": "2051", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4035.8, "maximum": 5246.54, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4035.8 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4096.34, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4237.59, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4439.38, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4439.38, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4035.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4035.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5246.54, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4035.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4035.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4035.8, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CELLULITIS & OTHER SKIN INFECTIONS - SOI : 4", "code_information": [ { "code": "3834", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14332.55, "maximum": 18632.31, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14332.55 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14547.54, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 15049.18, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15765.81, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 14332.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 15765.81, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14332.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14332.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18632.31, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 14332.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14332.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14332.55, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Colpocleisis Le Fort Type", "code_information": [ { "code": "57120", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 39617.5, "discounted_cash": 6402, "minimum": 872.17, "maximum": 35655.75, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 872.17 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6530.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 959.39 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 872.17 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 915.78 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 9603.68, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6466.47, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8181.18, "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": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8323.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 959.39 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 872.17 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 959.39 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 872.17 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6786.6, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 872.17 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 7682.94, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1133.82 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 872.17 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8181.24, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 872.17 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8434.27, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9603.68, "additional_payer_notes": "150.00% of Medicare Rates" } ] } ] }, { "description": "CAROTID ARTERY STENT PROCEDURES WITH CC", "code_information": [ { "code": "035", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 23792, "minimum": 8550, "maximum": 47140.66, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 23792.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 32120.4, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 24268.76, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 23792.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 23792.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 23792.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 23792.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 23792.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 23792.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 27670.04 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 24030.83, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42428.67 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 23792.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 23792.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 38663.45, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 30930.76, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 23792.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25220.47, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 23792.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 23792.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 28551.47, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 23792.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 23792.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 23792.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 39891.91 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 23792.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 23792.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 32906.9 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 47140.66 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 42426.59 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 23792.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 43740.9 } ] } ] }, { "description": "CESAREAN DELIVERY - SOI : 1", "code_information": [ { "code": "5401", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5389.76, "maximum": 7006.69, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5389.76 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5470.61, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 5659.25, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5928.74, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 5928.74, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5389.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5389.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7006.69, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 5389.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5389.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5389.76, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COMPLICATED PEPTIC ULCER WITH MCC", "code_information": [ { "code": "380", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19614, "minimum": 17919.2, "maximum": 38694.584, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 19615, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 26480.24, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 20007.3, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 19615, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 19615, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 19615, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 19614.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 19614.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 19615, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 22712.47 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 19811.15, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35891.26 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 19615, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 19614.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 31874.36, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 25499.49, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 19615, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20791.9, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 19615, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 19614.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 23537.99, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 19614.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19614.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19615, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 33802.74 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19615, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19614.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17919.2 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 38694.58 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 34825.13 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 19615, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37001.3 } ] } ] }, { "description": "Carpal Tunnel Surgery", "code_information": [ { "code": "64721", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19331, "discounted_cash": 2499, "minimum": 454.46, "maximum": 17397.9, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3748.83, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 454.46 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2549.2, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 499.91 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 454.46 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 477.18 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3748.83, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2524.21, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3193.55, "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": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3248.99, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 499.91 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 454.46 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 499.91 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 454.46 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2649.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 454.46 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 2999.06, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 590.8 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 454.46 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 454.46 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3193.58, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 454.46 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3292.35, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CESAREAN SECTION WITH STERILIZATION WITH MCC", "code_information": [ { "code": "783", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 24423, "minimum": 8000, "maximum": 39687.4238, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 24423, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 32971.09, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 24911.46, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 24423, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 24423, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 24423, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 24423.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 24423.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 24423, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8000 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 24667.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34358.18 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 24423, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 24423.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 39687.42, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 31749.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 24423, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25888.38, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 24423, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 20700, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 18000, "10th_percentile": 18000, "90th_percentile": 18000, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 24423.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 29307.64, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 24423.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 24423.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 24423, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 30737.33 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 24423, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 24423.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17423.6 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 11854 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 10669 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 24423, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35420.8 } ] } ] }, { "description": "COMPLICATED PEPTIC ULCER WITHOUT CCMCC", "code_information": [ { "code": "382", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8284, "minimum": 7097.05, "maximum": 15787.832, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 8284.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 11183.44, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8449.71, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8284.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 8284.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 8284.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 8284.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 8284.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8284.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 9266.95 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8366.87, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13975.66 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8284.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8284.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13461.55, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10769.24, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 8284.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8781.07, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8284.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 8284.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 9940.84, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8284.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8284.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8284.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13134.23 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8284.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8284.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7097.05 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 15787.83 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 14209.05 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8284.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14407.9 } ] } ] }, { "description": "CESAREAN SECTION WITH STERILIZATION WITHOUT CCMCC", "code_information": [ { "code": "785", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9817, "minimum": 8000, "maximum": 16796.1, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 9817.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 13253.57, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10013.81, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9817.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 9817.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 9817.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 9817.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 9817.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 9817.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8000 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9915.63, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16292.22 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9817.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9817.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15953.37, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12762.7, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 9817.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10406.51, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9817.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 11250, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 13500, "10th_percentile": 13500, "90th_percentile": 13500, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 9817.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 11780.95, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9817.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9817.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9817.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 15028.64 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9817.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9817.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9121.19 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 11854 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 10669 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 9817.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16796.1 } ] } ] }, { "description": "CHOLECYSTECTOMY WITH C.D.E. WITH CC", "code_information": [ { "code": "412", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20983, "minimum": 19800, "maximum": 41461.3, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 20983.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 28327.81, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 21403.27, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 20983.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 20983.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 20983.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 20983.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 20983.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 20983.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 24336.44 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 21193.44, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39757.78 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 20983.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 20983.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 34098.29, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 27278.63, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 20983.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22242.62, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 20983.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 20983.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 25180.27, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 20983.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20983.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20983.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 35842.87 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 20983.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20983.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 28322.4 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 41461.3 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 37315.17 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 20983.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40987.4 } ] } ] }, { "description": "CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES", "code_information": [ { "code": "212", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 106547, "minimum": 56250, "maximum": 214437.252, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 106547, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 143838.57, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 108677.94, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 106547, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 106547, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 106547, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 106547.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 106547.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 106547, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 125867.71 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 107612.47, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 203188.81 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 106547, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 106547.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 173139.02, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 138511.22, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 106547, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 112939.82, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 106547, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 106547.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 127856.51, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 106547.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 106547.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 106547, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 186850.98 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 106547, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 106547.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 144744 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 214437.25 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 192993.53 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 106547, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 209473 } ] } ] }, { "description": "CESAREAN SECTION WITH STERILIZATION- SOI : 2", "code_information": [ { "code": "5392", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6779.76, "maximum": 8813.69, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6779.76 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6881.46, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7118.75, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7457.74, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 7457.74, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6779.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6779.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8813.69, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 6779.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6779.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6779.76, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHOLECYSTECTOMY WITH C.D.E. WITHOUT CCMCC", "code_information": [ { "code": "413", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16672, "minimum": 12600, "maximum": 32745.06, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 16672, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 22507.23, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 17005.44, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 16672, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 16672, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 16672, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 16672.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 16672.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 16672, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 19220.29 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16838.72, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31008.28 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 16672, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 16672.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 27092.03, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 21673.63, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 16672, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17672.32, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 16672, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 16672.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 20006.42, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 16672.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16672.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16672, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 26188.66 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16672, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16672.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 22089.5 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 32745.06 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 29470.55 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 16672, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31967.3 } ] } ] }, { "description": "CORONARY BYPASS W AMI OR COMPLEX PDX - SOI : 4", "code_information": [ { "code": "1654", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 63659, "maximum": 82756.7, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 63659 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 64613.88, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 66841.95, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 70024.9, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 70024.9, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 63659, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 63659, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 82756.7, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 63659, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 63659, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 63659, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CESAREAN SECTION WITHOUT STERILIZATION WITH MCC", "code_information": [ { "code": "786", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16564, "minimum": 8000, "maximum": 31071.3, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 16564.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 22362.37, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 16895.99, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 16564.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 16564.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 16564.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 16564.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 16564.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 16564.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8000 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16730.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30139.16 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 16564.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 16564.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 26917.67, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 21534.14, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 16564.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17558.58, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 16564.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 18900, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 18000, "10th_percentile": 18000, "90th_percentile": 18000, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 16564.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 19877.66, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 16564.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16564.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16564.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 30350.47 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16564.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16564.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 11854 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 10669 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 16564.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31071.3 } ] } ] }, { "description": "CHOLECYSTECTOMY- SOI : 1", "code_information": [ { "code": "2631", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9312.98, "maximum": 12106.87, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9312.98 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9452.67, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 9778.63, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10244.28, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 10244.28, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9312.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9312.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12106.87, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 9312.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9312.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9312.98, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CORONARY BYPASS WITH PTCA WITH MCC", "code_information": [ { "code": "231", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 82704, "minimum": 48600, "maximum": 166237.628, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 82704.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 111651.59, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 84359, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 82704.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 82704.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 82704.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 82704.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 82704.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 82704.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 97576.09 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 83531.95, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 158051.9 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 82704.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 82704.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 134395.43, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 107516.34, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 82704.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 87667.19, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 82704.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 82704.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 99245.86, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 82704.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 82704.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 82704.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 140783.15 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 82704.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 82704.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 70914.2 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 166237.63 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 149613.87 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 82704.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 162940.1 } ] } ] }, { "description": "CHEMOTHERAPY FOR ACUTE LEUKEMIA - SOI : 2", "code_information": [ { "code": "6952", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8459.6, "maximum": 10997.48, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8459.6 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8586.49, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 8882.58, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9305.56, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 9305.56, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8459.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8459.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10997.48, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 8459.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8459.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8459.6, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHOLECYSTECTOMY- SOI : 3", "code_information": [ { "code": "2633", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16322.36, "maximum": 21219.07, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16567.2, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 17138.48, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17954.6, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 17954.6, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16322.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16322.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21219.07, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 16322.36, "additional_payer_notes": "100% 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16322.36 } ] } ] }, { "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": 38699.27, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29768.67 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 30215.2, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 31257.1, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32745.54, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 32745.54, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29768.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 29768.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38699.27, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 29768.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29768.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 29768.67, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHEMOTHERAPY FOR ACUTE LEUKEMIA - SOI : 3", "code_information": [ { "code": "6953", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16628.73, "maximum": 21617.35, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16628.73 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16878.16, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 17460.17, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18291.6, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 18291.6, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16628.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16628.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21617.35, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 16628.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16628.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16628.73, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHRONIC KIDNEY DISEASE - SOI : 2", "code_information": [ { "code": "4702", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4928.4, "maximum": 6406.92, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4928.4 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5002.33, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 5174.82, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5421.24, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 5421.24, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4928.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4928.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6406.92, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4928.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4928.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4928.4, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC", "code_information": [ { "code": "846", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 25763, "minimum": 18666.1, "maximum": 51124.1, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 25763.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 34780.48, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 26278.57, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 25763.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 25763.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 25763.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 25763.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 25763.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 25763.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 30008.19 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 26020.93, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 47632.53 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 25763.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 25763.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 41865.4, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 33492.32, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 25763.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 27309.1, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 25763.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 25763.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 30915.98, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 25763.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 25763.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 25763.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 42398.71 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 25763.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 25763.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18666.1 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 51124.1 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 46011.69 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 25763.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 49105.7 } ] } ] }, { "description": "Circum 28 Days Or Older", "code_information": [ { "code": "54161", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19618, "discounted_cash": 2675, "minimum": 181.5664, "maximum": 17656.2, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4013.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2728.92, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 199.73 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 190.65 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 4013.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2702.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3418.69, "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": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3478.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 199.73 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 199.73 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2835.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 3210.49, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 236.04 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "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": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3418.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3524.45, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC", "code_information": [ { "code": "026", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 30803, "minimum": 13500, "maximum": 61313.424, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 30803.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 41584.75, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 31419.57, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 30803.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 30803.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 30803.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 30803.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 30803.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 30803.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 35988.99 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 31111.54, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 57047.83 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 30803.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 30803.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 50055.72, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 40044.58, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 30803.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 32651.71, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 30803.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 30803.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 36964.22, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 30803.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 30803.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 30803.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 51230.62 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 30803.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 30803.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 33997.4 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 61313.42 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 55182.08 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 30803.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 58812.2 } ] } ] }, { "description": "CHEST PAIN - SOI : 4", "code_information": [ { "code": "2034", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9476.23, "maximum": 12319.1, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9476.23 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9618.37, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 9950.04, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10423.85, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 10423.85, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9476.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9476.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12319.1, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 9476.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9476.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9476.23, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC", "code_information": [ { "code": "432", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19673, "minimum": 19673.5, "maximum": 38812.904, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 19673.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 26559.24, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 20066.97, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 19673.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 19673.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 19673.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 19673.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 19673.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 19673.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 22781.92 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 19870.24, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36540.39 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 19673.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 19673.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 31969.45, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 25575.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 19673.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20853.91, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 19673.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 19673.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 23608.21, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 19673.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19673.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19673.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 33238.92 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19673.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19673.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23712.7 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 38812.9 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 34931.61 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 19673.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37670.5 } ] } ] }, { "description": "CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA - SOI : 3", "code_information": [ { "code": "9103", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 33747.22, "maximum": 43871.39, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33747.22 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34253.43, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 35434.58, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 37121.94, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 37121.94, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33747.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 33747.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 43871.39, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 33747.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33747.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 33747.22, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA - SOI : 4", "code_information": [ { "code": "9104", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 56988.86, "maximum": 74085.52, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 56988.86 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 57843.69, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 59838.3, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 62687.75, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 62687.75, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 56988.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 56988.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 74085.52, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 56988.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 56988.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 56988.86, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC", "code_information": [ { "code": "414", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 35226, "minimum": 34200, "maximum": 70254.472, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 35226.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 47555.45, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 35930.83, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 35226.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 35226.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 35226.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 35226.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 35226.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 35226.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 41237.1 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 35578.56, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 65351.52 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 35226.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 35226.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 57242.67, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 45794.14, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 35226.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 37339.88, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 35226.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 35226.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 42271.51, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 35226.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 35226.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 35226.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 61155.46 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 35226.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 35226.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 46554 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 70254.47 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 63229.02 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 35226.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 67372.7 } ] } ] }, { "description": "CLEFT LIP & PALATE REPAIR - SOI : 1", "code_information": [ { "code": "0951", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7198.08, "maximum": 9357.5, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7198.08 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7306.05, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7557.98, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7917.89, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 7917.89, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7198.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7198.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9357.5, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 7198.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7198.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7198.08, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CVA & PRECEREBRAL OCCLUSION W INFARCT - SOI : 1", "code_information": [ { "code": "0451", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6539.76, "maximum": 8501.69, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6539.76 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6637.86, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 6866.75, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7193.74, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 7193.74, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6539.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6539.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8501.69, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 6539.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6539.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6539.76, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CELLULITIS & OTHER SKIN INFECTIONS - SOI : 2", "code_information": [ { "code": "3832", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5117.1, "maximum": 6652.23, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5117.1 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5193.86, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 5372.96, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5628.81, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 5628.81, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5117.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5117.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6652.23, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 5117.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5117.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5117.1, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHOLECYSTECTOMY WITH C.D.E. WITH MCC", "code_information": [ { "code": "411", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 32696, "minimum": 25650, "maximum": 65141.076, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 32696.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 44140.8, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 33350.84, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 32696.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 32696.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 32696.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 32696.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 32696.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 32696.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 38235.7 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 33023.87, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 51038.3 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 32696.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 32696.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 53132.45, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 42505.96, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 32696.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 34658.71, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 32696.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 32696.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 39236.27, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 32696.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 32696.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 32696.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 52745.11 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 32696.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 32696.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 36357.9 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 65141.08 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 58626.97 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 32696.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 52616.8 } ] } ] }, { "description": "CLEFT LIP & PALATE REPAIR - SOI : 4", "code_information": [ { "code": "0954", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 19181.45, "maximum": 24935.89, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19181.45 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19469.17, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 20140.52, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21099.6, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 21099.6, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19181.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 19181.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24935.89, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 19181.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19181.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 19181.45, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CVA & PRECEREBRAL OCCLUSION W INFARCT - SOI : 4", "code_information": [ { "code": "0454", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16939.34, "maximum": 22021.14, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16939.34 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17193.43, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 17786.31, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18633.27, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 18633.27, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16939.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16939.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22021.14, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 16939.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16939.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16939.34, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CELLULITIS WITHOUT MCC", "code_information": [ { "code": "603", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8969, "minimum": 6837.3, "maximum": 17174.148, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 8969.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 12109.2, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9149.18, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8969.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 8969.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 8969.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 8969.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 8969.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8969.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 10080.67 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9059.48, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16428.31 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8969.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8969.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14575.89, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11660.71, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 8969.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9507.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8969.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 8969.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 10763.74, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8969.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8969.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8969.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 15347.85 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8969.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8969.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6837.3 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 17174.15 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 15456.73 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8969.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16936.4 } ] } ] }, { "description": "CHOLECYSTECTOMY- SOI : 2", "code_information": [ { "code": "2632", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11931.43, "maximum": 15510.86, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11931.43 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12110.4, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 12528, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13124.57, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 13124.57, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11931.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11931.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15510.86, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 11931.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11931.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11931.43, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Cltx Mndblr Fx Ntrdntl Fixj", "code_information": [ { "code": "21453", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 28604, "discounted_cash": 7576, "minimum": 483.82, "maximum": 25743.6, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11364.87, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7728.11, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 532.2 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 508.01 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 11364.87, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7652.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9681.51, "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": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9849.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 532.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 532.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8031.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 9091.9, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 628.97 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "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": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9681.57, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "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": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9981.01, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CERVICAL SPINAL FUSION WITH CC", "code_information": [ { "code": "472", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 29212, "minimum": 11250, "maximum": 58097.092, "payers_information": [ { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 29212.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 29212.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 29212.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 51270.52 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 29212.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 29212.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 33006.3 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 58097.09 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 52287.38 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 29212.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 55708.7 }, { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 29212.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 39436.94, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 29796.75, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 29212.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 29212.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 29212.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 29212.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 29212.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 29212.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 34101.11 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 29504.63, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 54037.44 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 29212.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 29212.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 47470.39, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 37976.32, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 29212.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 30965.25, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 29212.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 29212.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 35055.06, "additional_payer_notes": "120.00% of Medicare Rates" } ] } ] }, { "description": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE - SOI : 4", "code_information": [ { "code": "1404", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12433.91, "maximum": 16164.08, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12433.91 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12620.42, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 13055.61, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13677.3, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 13677.3, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12433.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12433.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16164.08, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 12433.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12433.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12433.91, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CMBN ANT PST COLPRHY", "code_information": [ { "code": "57260", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 30738.7, "discounted_cash": 6402, "minimum": 872.17, "maximum": 27664.803, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9603.68, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 872.17 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6530.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 959.39 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 872.17 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 915.78 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 9603.68, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6466.47, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8181.18, "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": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8323.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 959.39 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 872.17 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 959.39 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 872.17 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6786.6, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 872.17 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 7682.94, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1133.82 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 872.17 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8181.24, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 872.17 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8434.27, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 30738.67, "discounted_cash": 6402, "minimum": 872.17, "maximum": 27664.803, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9603.68, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 872.17 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6530.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 959.39 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 872.17 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 915.78 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 9603.68, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6466.47, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8181.18, "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": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8323.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 959.39 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 872.17 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 959.39 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 872.17 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6786.6, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 872.17 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 7682.94, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1133.82 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 872.17 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8181.24, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 872.17 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8434.27, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CERVICAL SPINAL FUSION WITHOUT CCMCC", "code_information": [ { "code": "473", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 24288, "minimum": 7200, "maximum": 48142.436, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 24288.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 32789.37, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 24774.17, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 24288.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 24288.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 24288.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 24288.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 24288.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 24288.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 28258.05 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 24531.28, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 44155.86 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 24288.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 24288.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 39468.68, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 31574.95, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 24288.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25745.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 24288.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 24288.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 29146.1, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 24288.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 24288.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 24288.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 42686.69 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 24288.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 24288.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 28201.5 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 48142.44 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 43328.19 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 24288.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 45521.5 } ] } ] }, { "description": "COAGULATION & PLATELET DISORDERS - SOI : 1", "code_information": [ { "code": "6611", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6078.61, "maximum": 7902.19, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6078.61 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6169.79, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 6382.54, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6686.47, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 6686.47, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6078.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6078.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7902.19, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 6078.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6078.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6078.61, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Cystoscopy And Treatment - 52281 - OR36052281", "code_information": [ { "code": "52281", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 26365.3, "discounted_cash": 2675, "minimum": 181.5664, "maximum": 23728.77, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4013.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2728.92, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 199.73 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 190.65 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 4013.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2702.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3418.69, "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": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3478.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 199.73 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 199.73 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2835.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 3210.49, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 236.04 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "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": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3418.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3524.45, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CESAREAN DELIVERY - SOI : 3", "code_information": [ { "code": "5403", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9359.2, "maximum": 12166.96, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9359.2 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9499.59, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 9827.16, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10295.12, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 10295.12, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9359.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9359.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12166.96, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 9359.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9359.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9359.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COAGULATION & PLATELET DISORDERS - SOI : 4", "code_information": [ { "code": "6614", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 19298.06, "maximum": 25087.48, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19298.06 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19587.53, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 20262.96, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21227.87, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 21227.87, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19298.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 19298.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25087.48, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 19298.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19298.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 19298.06, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Cystoscopy W/Biopsy(S)", "code_information": [ { "code": "52204", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16507, "discounted_cash": 2675, "minimum": 195.98, "maximum": 14856.3, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4013.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.98 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2728.92, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 215.58 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.98 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 205.78 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 4013.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2702.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3418.69, "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": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3478.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 215.58 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 195.98 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 215.58 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.98 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2835.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 195.98 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 3210.49, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 254.77 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 195.98 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.98 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3418.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 195.98 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3524.45, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CESAREAN SECTION WITH STERILIZATION WITH CC", "code_information": [ { "code": "784", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10815, "minimum": 8000, "maximum": 20824.4, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 10815.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 14600.72, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11031.71, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 10815.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 10815.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 10815.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 10815.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 10815.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 10815.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8000 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10923.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20199.67 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10815.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 10815.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 17574.94, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14059.96, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 10815.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11464.32, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10815.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 10815.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 12978.42, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10815.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10815.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10815.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 17766.17 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10815.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10815.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10993.3 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 11854 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 10669 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 10815.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20824.4 } ] } ] }, { "description": "COCAINE ABUSE & DEPENDENCE - SOI : 1", "code_information": [ { "code": "7741", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2749.9, "maximum": 3574.87, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2749.9 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2791.15, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 2887.4, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3024.89, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 3024.89, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2749.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 2749.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3574.87, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 2749.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2749.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 2749.9, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CESAREAN SECTION WITHOUT STERILIZATION WITH CC", "code_information": [ { "code": "787", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11368, "minimum": 8000, "maximum": 20416.8, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 11368.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 15347.39, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11595.77, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11368.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 11368.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 11368.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 11368.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 11368.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 11368.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8000 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11482.08, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19804.3 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11368.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 11368.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18473.72, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14778.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 11368.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12050.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11368.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 14850, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 13500, "10th_percentile": 13500, "90th_percentile": 18000, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 11368.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 13642.13, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11368.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11368.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11368.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 18234.57 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11368.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11368.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16272.1 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 11854 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 10669 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 11368.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20416.8 } ] } ] }, { "description": "CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CCMCC", "code_information": [ { "code": "434", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7424, "minimum": 7424.65, "maximum": 14050.5, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 7424.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 10023.28, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7573.14, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7424.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 7424.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 7424.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 7424.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 7424.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 7424.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8247.19 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7498.9, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12990.82 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7424.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7424.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12065.06, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9652.05, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 7424.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7870.13, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7424.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 7424.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 8909.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7424.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7424.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7424.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 11614.54 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7424.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7424.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7957.7 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 14050.5 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 12645.45 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 7424.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13392.6 } ] } ] }, { "description": "COCAINE ABUSE & DEPENDENCE - SOI : 2", "code_information": [ { "code": "7742", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3481.37, "maximum": 4525.78, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3481.37 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3533.59, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3481.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3655.44, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3829.51, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 3829.51, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3481.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3481.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4525.78, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 3481.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3481.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3481.37, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHEMOTHERAPY FOR ACUTE LEUKEMIA - SOI : 4", "code_information": [ { "code": "6954", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 39025.46, "maximum": 50733.1, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39025.46 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39610.84, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 40976.73, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42928.01, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 42928.01, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39025.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 39025.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 50733.1, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 39025.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39025.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 39025.46, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC", "code_information": [ { "code": "454", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 106106.07, "maximum": 106106.07, "payers_information": [ { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 106106.07 } ] } ] }, { "description": "Dbrdmt Musc&/Fsca 1St 20/<", "code_information": [ { "code": "11043", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14942, "discounted_cash": 945, "minimum": 224.8279, "maximum": 13447.8, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1418.87, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 224.83 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 964.83, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 247.31 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 224.83 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "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": 236.07 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 1418.87, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 955.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1208.7, "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": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1229.68, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 247.31 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 224.83 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 247.31 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 224.83 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1002.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 224.83 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 1135.09, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 292.28 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 224.83 }, { "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": 224.83 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1208.71, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 224.83 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1246.09, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "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": 20836, "minimum": 18612.3, "maximum": 41163.528, "payers_information": [ { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20836.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18612.3 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 41163.53 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 37047.18 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 20836.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38999.2 }, { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 20836.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 28128.95, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 21253.03, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 20836.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 20836.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 20836.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 20836.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 20836.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 20836.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 24161.66 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 21044.66, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37829.22 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 20836.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 20836.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 33858.92, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 27087.14, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 20836.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22086.48, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 20836.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 20836.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 25003.51, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 20836.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20836.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20836.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 34725.65 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 20836.3, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CCMCC", "code_information": [ { "code": "455", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 79898.32, "maximum": 79898.32, "payers_information": [ { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 79898.32 } ] } ] }, { "description": "DEFIBRILLATOR IMPLANTS- SOI : 2", "code_information": [ { "code": "1792", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 33373.01, "maximum": 43384.91, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33373.01 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33873.61, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 35041.66, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36710.31, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 36710.31, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33373.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 33373.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 43384.91, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 33373.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33373.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 33373.01, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CCMCC", "code_information": [ { "code": "839", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14559, "minimum": 12311.2, "maximum": 28473.708, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 14559.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 19654.88, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 14850.38, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 14559.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 14559.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 14559.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 14559.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 14559.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 14559.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 16713.14 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 14704.79, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25560.18 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 14559.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 14559.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 23658.65, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 18926.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 14559.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15432.75, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 14559.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 14559.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 17471, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 14559.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14559.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14559.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 22606.28 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14559.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14559.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12311.2 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 28473.71 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 25626.34 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 14559.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26350.7 } ] } ] }, { "description": "COMPLICATIONS OF TREATMENT WITH CC", "code_information": [ { "code": "920", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10251, "minimum": 9886.08, "maximum": 19765.356, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 10251.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 13839.58, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10456.53, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 10251.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 10251.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 10251.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 10251.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 10251.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 10251.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 11601.62 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10354.02, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18948.17 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10251.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 10251.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16658.75, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13327, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 10251.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10866.59, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10251.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 10251.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 12301.85, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10251.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10251.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10251.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 17934.45 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10251.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10251.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9886.08 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 19765.36 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 17788.82 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 10251.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19534.2 } ] } ] }, { "description": "DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC", "code_information": [ { "code": "057", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13112, "minimum": 13112.56, "maximum": 25658.5, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 13112.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 17701.96, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13374.85, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 13112.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 13112.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 13112.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 13112.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 13112.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 13112.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 14996.57 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13243.73, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24888.75 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 13112.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 13112.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21307.91, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 17046.33, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 13112.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13899.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13112.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 13112.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 15735.07, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13112.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13112.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13112.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 23648.9 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13112.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13112.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19341.2 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 25549.23 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 22994.31 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 13112.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25658.5 } ] } ] }, { "description": "CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC", "code_information": [ { "code": "847", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13235, "minimum": 10817.3, "maximum": 25797.704, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 13235.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 17867.88, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13500.21, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 13235.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 13235.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 13235.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 13235.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 13235.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 13235.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 15142.42 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13367.86, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23700.59 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 13235.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 13235.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21507.64, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 17206.11, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 13235.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14029.63, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13235.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 13235.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 15882.56, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13235.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13235.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13235.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 21036.28 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13235.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13235.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10817.3 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 25797.7 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 23217.93 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 13235.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24433.6 } ] } ] }, { "description": "COMPLICATIONS OF TREATMENT WITH MCC", "code_information": [ { "code": "919", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18333, "minimum": 17068.1, "maximum": 36103.376, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 18333.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 24749.86, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 18699.86, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 18333.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 18333.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 18333.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 18333.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 18333.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 18333.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 21191.51 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18516.53, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34013.05 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 18333.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 18333.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 29791.5, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 23833.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 18333.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19433.19, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 18333.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 18333.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 21999.88, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 18333.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18333.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18333.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 31655.04 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18333.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18333.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17068.1 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 36103.38 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 32493.04 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 18333.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35065 } ] } ] }, { "description": "DENTAL AND ORAL DISEASES WITHOUT CCMCC", "code_information": [ { "code": "159", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7385, "minimum": 6976.15, "maximum": 13971.62, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 7385.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 9970.6, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7533.34, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7385.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 7385.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 7385.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 7385.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 7385.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 7385.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8200.89 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7459.49, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12302.61 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7385.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7385.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12001.65, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9601.32, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 7385.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7828.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7385.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 9000, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 4500, "10th_percentile": 4500, "90th_percentile": 4500, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 7385.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 8862.76, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7385.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7385.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7385.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 11713.42 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7385.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7385.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6976.15 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 13971.62 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 12574.46 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 7385.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12683.1 } ] } ] }, { "description": "CHEST PAIN - SOI : 2", "code_information": [ { "code": "2032", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4785.29, "maximum": 6220.88, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4785.29 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4857.07, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 5024.55, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5263.82, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 5263.82, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4785.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4785.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6220.88, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4785.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4785.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4785.29, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CONCUSSION WITHOUT CCMCC", "code_information": [ { "code": "090", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8504, "minimum": 8504.48, "maximum": 16484.6, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 8504.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 11481.05, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8674.57, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8504.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 8504.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 8504.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 8504.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 8504.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8504.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 9528.54 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8589.52, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15990.06 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8504.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8504.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13819.78, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11055.82, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 8504.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9014.75, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8504.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 8504.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 10205.38, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8504.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8504.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8504.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 16216.99 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8504.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8504.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14917.1 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 16233.5 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 14610.15 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8504.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16484.6 } ] } ] }, { "description": "DEPRESSIVE NEUROSES", "code_information": [ { "code": "881", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9652, "minimum": 4800, "maximum": 18554.548, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 9652.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 13031.01, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9845.65, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9652.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 9652.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 9652.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 9652.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 9652.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 9652.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 10890.92 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9749.13, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17049.4 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9652.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9652.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15685.48, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12548.38, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 9652.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10231.76, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9652.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 9652.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 11583.12, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9652.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9652.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9652.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 15726.04 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9652.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9652.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5491.86 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 18554.55 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 16699.09 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 9652.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17576.7 } ] } ] }, { "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": 5784.01, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4449.24 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4515.98, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4671.7, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4894.16, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4894.16, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4449.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4449.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5784.01, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4449.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4449.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4449.24, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 21624.24, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16634.03 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16883.54, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 17465.73, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18297.43, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 18297.43, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16634.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16634.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21624.24, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 16634.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16634.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16634.03, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHOLECYSTECTOMY- SOI : 4", "code_information": [ { "code": "2634", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 27036.79, "maximum": 35147.83, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27036.79 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27442.34, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 28388.63, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29740.47, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 29740.47, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27036.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 27036.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35147.83, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 27036.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27036.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 27036.79, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Conization Of Cervix - 57520 - OR36057520", "code_information": [ { "code": "57520", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15307.8, "discounted_cash": 4143, "minimum": 369.9461, "maximum": 13777.02, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6214.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 369.95 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4225.94, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 406.95 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 369.95 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 388.45 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6214.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4184.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5294.11, "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": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5386, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 406.95 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 369.95 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 406.95 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 369.95 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4391.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 369.95 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 4971.7, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 480.94 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 369.95 }, { "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": 369.95 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5294.15, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 369.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5457.89, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CHRONIC KIDNEY DISEASE - SOI : 3", "code_information": [ { "code": "4703", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8182.91, "maximum": 10637.78, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8182.91 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8305.65, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 8592.06, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9001.2, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 9001.2, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8182.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8182.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10637.78, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 8182.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8182.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8182.91, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COAGULATION & PLATELET DISORDERS - SOI : 3", "code_information": [ { "code": "6613", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11209.5, "maximum": 14572.35, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11209.5 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11377.64, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 11769.98, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12330.45, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 12330.45, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11209.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11209.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14572.35, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 11209.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11209.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11209.5, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS - SOI : 2", "code_information": [ { "code": "3462", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7614.7, "maximum": 9899.11, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7614.7 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7728.92, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7995.44, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8376.17, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 8376.17, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7614.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7614.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9899.11, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 7614.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7614.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7614.7, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE - SOI : 1", "code_information": [ { "code": "1401", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4604.01, "maximum": 5985.21, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4604.01 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4673.07, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4834.21, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5064.41, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 5064.41, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4604.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4604.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5985.21, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4604.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4604.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4604.01, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COAGULATION DISORDERS", "code_information": [ { "code": "813", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15353, "minimum": 14975.7, "maximum": 30078.916, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 15353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 20726.82, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 15660.26, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 15353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 15353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 15353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 15353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 15353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 15353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 17655.35 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15506.73, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28872.73 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 15353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 15353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 24948.95, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 19959.16, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 15353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16274.39, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 15353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 15353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 18423.84, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 27063.01 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14975.7 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 30078.92 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 27071.02 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 15353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29765.7 } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS WITH CC", "code_information": [ { "code": "546", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11725, "minimum": 11725.46, "maximum": 22745.048, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 11725.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 15829.37, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11960.01, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11725.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 11725.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 11725.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 11725.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 11725.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 11725.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 13350.61 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11842.76, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21592.98 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11725.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 11725.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 19053.87, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 15243.1, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 11725.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12429.03, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11725.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 11725.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 14070.55, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11725.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11725.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11725.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 20805.55 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11725.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11725.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15044 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 22745.05 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 20470.54 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 11725.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22260.8 } ] } ] }, { "description": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE - SOI : 2", "code_information": [ { "code": "1402", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5528.42, "maximum": 7186.95, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5528.42 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5611.35, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 5804.84, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6081.26, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 6081.26, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5528.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5528.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7186.95, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 5528.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5528.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5528.42, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COCAINE ABUSE & DEPENDENCE - SOI : 3", "code_information": [ { "code": "7743", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5959.88, "maximum": 7747.84, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5959.88 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6049.28, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 6257.87, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6555.87, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 6555.87, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5959.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5959.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7747.84, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 5959.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5959.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5959.88, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 7982.13, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6140.1 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6232.2, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 6447.11, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6754.11, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 6754.11, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6140.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6140.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7982.13, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 6140.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6140.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6140.1, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC", "code_information": [ { "code": "190", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11279, "minimum": 10809, "maximum": 21843.844, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 11279.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 15227.55, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11505.29, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11279.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 11279.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 11279.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 11279.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 11279.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 11279.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 12821.63 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11392.5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20945.79 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11279.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 11279.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18329.46, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14663.57, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 11279.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11956.48, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11279.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 11279.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 13535.6, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11279.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11279.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11279.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 19117.59 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11279.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11279.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10809 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 21843.84 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 19659.46 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 11279.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21593.6 } ] } ] }, { "description": "COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH MCC", "code_information": [ { "code": "453", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 153728.29, "maximum": 153728.29, "payers_information": [ { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 153728.29 } ] } ] }, { "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": 45771.83, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35209.1 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35737.24, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 36969.56, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38730.01, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 38730.01, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35209.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 35209.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45771.83, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 35209.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35209.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 35209.1, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CCMCC", "code_information": [ { "code": "192", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6736, "minimum": 5993.41, "maximum": 12660.24, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 6736.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 9094.88, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6871.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6736.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 6736.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 6736.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 6736.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 6736.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 6736.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 7431.15 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6804.32, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12071.36 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6736.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6736.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 10947.54, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 8758.04, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 6736.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7141.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6736.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 6736.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 8084.34, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6736.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6736.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6736.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 11134 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6736.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6736.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5993.41 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 12660.24 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 11394.22 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 6736.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12444.7 } ] } ] }, { "description": "COMPLICATED PEPTIC ULCER WITH CC", "code_information": [ { "code": "381", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11043, "minimum": 11043.6, "maximum": 21366.62, "payers_information": [ { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11043.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 11043.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 13252.33, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11043.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11043.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11043.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 18614.49 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11043.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11043.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12017.9 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 21366.62 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 19229.96 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 11043.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20941.7 }, { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 11043.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 14908.87, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11264.47, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11043.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 11043.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 11043.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 11043.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 11043.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 11043.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 12541.51 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11154.04, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20313.45 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11043.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 11043.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 17945.87, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14356.69, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 11043.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11706.22, "additional_payer_notes": "106.00% of Medicare 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": 50136.37, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38566.44 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39144.94, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 40494.76, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42423.08, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 42423.08, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38566.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 38566.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 50136.37, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 38566.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38566.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 38566.44, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC", "code_information": [ { "code": "286", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 22059, "minimum": 22059.49, "maximum": 43636.416, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 22059.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 29780.31, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 22500.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 22059.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 22059.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 22059.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 22059.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 22059.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 22059.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 25613.16 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 22280.1, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 41281.65 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 22059.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 22059.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 35846.67, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 28677.34, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 22059.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 23383.07, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 22059.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 24300, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 63000, "10th_percentile": 63000, "90th_percentile": 63000, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 22059.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 26471.39, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 22059.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 22059.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 22059.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 37395.52 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 22059.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 22059.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24399.8 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 43636.42 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 39272.77 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 22059.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42558.4 } ] } ] }, { "description": "COMPLICATIONS OF TREATMENT WITHOUT CCMCC", "code_information": [ { "code": "921", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7189, "minimum": 7189.56, "maximum": 13575.248, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 7189.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 9705.91, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7333.35, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7189.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 7189.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 7189.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 7189.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 7189.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 7189.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 7968.23 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7261.46, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12826.7 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7189.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7189.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11683.04, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9346.43, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 7189.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7620.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7189.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 7189.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 8627.47, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7189.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7189.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7189.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12105.49 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7189.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7189.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7195.2 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 13575.25 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 12217.72 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 7189.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13223.4 } ] } ] }, { "description": "CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC", "code_information": [ { "code": "234", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 53761, "minimum": 36450, "maximum": 107724.444, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 53761, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 72577.35, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 54836.22, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 53761, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 53761, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 53761, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 53761, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 53761, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 53761, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 63230.75 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 54298.61, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 99230.32 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 53761, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 53761, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 87361.63, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 69889.3, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 53761, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 56986.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 53761, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 53761, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 64513.2, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 53761, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 53761, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 53761, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 90173.59 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 53761, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 53761, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 77045.3 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 107724.44 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 96952 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 53761, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 102299.3 } ] } ] }, { "description": "CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC", "code_information": [ { "code": "433", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10777, "minimum": 10777.3, "maximum": 20828.264, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 10777.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 14549.37, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10992.85, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 10777.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 10777.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 10777.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 10777.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 10777.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 10777.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 12225.52 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10885.07, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19953.48 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10777.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 10777.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 17513.13, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14010.5, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 10777.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11423.94, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10777.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 10777.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 12932.77, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10777.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10777.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10777.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 17885.87 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10777.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10777.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12081.4 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 20828.26 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 18745.44 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 10777.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20570.6 } ] } ] }, { "description": "CONCUSSION WITH CC", "code_information": [ { "code": "089", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11190, "minimum": 11190.9, "maximum": 21664.392, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 11190.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 15107.72, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11414.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11190.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 11190.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 11190.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 11190.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 11190.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 11190.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 12716.3 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11302.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19996.36 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11190.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 11190.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18185.21, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14548.17, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 11190.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11862.35, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11190.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 11190.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 13429.08, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11190.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11190.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11190.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 19948.56 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11190.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11190.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18208.8 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 21664.39 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 19497.95 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 11190.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20614.8 } ] } ] }, { "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": 42982.5, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33063.46 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33559.41, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 34716.63, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36369.81, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 36369.81, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33063.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 33063.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42982.5, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 33063.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33063.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 33063.46, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CLEFT LIP & PALATE REPAIR - SOI : 3", "code_information": [ { "code": "0953", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10607.36, "maximum": 13789.57, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10607.36 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10766.47, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 11137.73, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11668.1, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 11668.1, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10607.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10607.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13789.57, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 10607.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10607.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10607.36, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 8992.3, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6917.15 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7020.91, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7263.01, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7608.86, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 7608.86, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6917.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6917.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8992.3, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 6917.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6917.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6917.15, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CORONARY BYPASS WO AMI OR COMPLEX PDX - SOI : 3", "code_information": [ { "code": "1663", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 39961.53, "maximum": 51949.99, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39961.53 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 40560.95, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 41959.61, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 43957.68, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 43957.68, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39961.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 39961.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 51949.99, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 39961.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39961.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 39961.53, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Diag Laparo Separate Proc", "code_information": [ { "code": "49320", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 33888, "discounted_cash": 7737, "minimum": 335.9078, "maximum": 30499.2, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11606.18, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 335.91 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7892.2, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 369.5 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 335.91 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 352.71 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 11606.18, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7814.82, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9887.07, "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": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10058.69, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 369.5 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 335.91 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 369.5 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 335.91 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8201.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 335.91 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 9284.94, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 436.68 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 335.91 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "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": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9887.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 335.91 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10192.93, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS - SOI : 1", "code_information": [ { "code": "3461", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5540.08, "maximum": 7202.1, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5540.08 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5623.18, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 5817.08, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6094.09, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 6094.09, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5540.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5540.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7202.1, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 5540.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5540.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5540.08, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE", "code_information": [ { "code": "325", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 31790, "minimum": 12150, "maximum": 63309.088, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 31790.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 42917.43, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 32426.51, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 31790.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 31790.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 31790.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 31790.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 31790.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 31790.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 37160.38 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 32108.61, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 53382.79 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 31790.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 31790.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 51659.87, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 41327.9, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 31790.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 33698.14, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 31790.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 31790.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 38148.83, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 31790.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 31790.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 31790.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 45873.53 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 31790.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 31790.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 38027.7 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 63309.09 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 56978.18 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 31790.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 55033.8 } ] } ] }, { "description": "DIGESTIVE MALIGNANCY - SOI : 2", "code_information": [ { "code": "2402", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7210.8, "maximum": 9374.04, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7210.8 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7318.96, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7571.34, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7931.88, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 7931.88, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7210.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7210.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9374.04, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 7210.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7210.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7210.8, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COAGULATION & PLATELET DISORDERS - SOI : 2", "code_information": [ { "code": "6612", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7714.35, "maximum": 10028.66, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7714.35 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7830.07, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 8100.07, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8485.79, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 8485.79, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7714.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7714.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10028.66, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 7714.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7714.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7714.35, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS - SOI : 4", "code_information": [ { "code": "3464", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 21898.49, "maximum": 28468.04, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21898.49 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22226.97, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 22993.41, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24088.34, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 24088.34, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21898.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 21898.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28468.04, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 21898.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21898.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 21898.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC", "code_information": [ { "code": "073", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16123, "minimum": 16123.8, "maximum": 31636.796, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 16123.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 21767.14, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 16446.28, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 16123.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 16123.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 16123.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 16123.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 16123.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 16123.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 18569.77 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16285.04, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28827.92 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 16123.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 16123.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 26201.19, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 20960.95, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 16123.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17091.23, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 16123.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 16123.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 19348.57, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 16123.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16123.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16123.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 26247.65 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16123.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16123.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18012.5 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 31636.8 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 28473.12 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 16123.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29719.5 } ] } ] }, { "description": "DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES - SOI : 3", "code_information": [ { "code": "5173", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12821.91, "maximum": 16668.48, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12821.91 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13014.24, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 13463.01, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14104.1, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 14104.1, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12821.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12821.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16668.48, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 12821.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12821.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12821.91, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS WITHOUT CCMCC", "code_information": [ { "code": "547", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8631, "minimum": 8631.29, "maximum": 16489.864, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 8631.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 11652.24, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8803.92, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8631.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 8631.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 8631.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 8631.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 8631.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8631.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 9679.02 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8717.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13917.85 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8631.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8631.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14025.85, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11220.68, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 8631.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9149.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8631.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 8631.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 10357.55, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8631.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8631.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8631.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 14282.68 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8631.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8631.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9673.01 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 16489.86 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 14840.88 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8631.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14348.3 } ] } ] }, { "description": "CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC", "code_information": [ { "code": "074", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10529, "minimum": 10529.5, "maximum": 20327.376, "payers_information": [ { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 17802.6 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10529.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10529.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11216 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 20327.38 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 18294.64 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 10529.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20043.8 }, { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 10529.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 14214.88, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10740.09, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 10529.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 10529.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 10529.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 10529.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 10529.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 10529.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 11931.51 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10634.8, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19442.49 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10529.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 10529.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 17110.5, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13688.4, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 10529.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11161.27, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10529.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 10529.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 12635.45, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10529.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10529.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10529.5, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "Dilation Of Cervical Canal", "code_information": [ { "code": "57800", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8252, "discounted_cash": 4143, "minimum": 49.4294, "maximum": 7426.8, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6214.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 49.43 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4225.94, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 54.37 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 49.43 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 51.9 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6214.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4184.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5294.11, "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": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5386, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.37 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 49.43 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 54.37 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 49.43 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4391.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 49.43 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 4971.7, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 64.26 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 49.43 }, { "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": 49.43 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5294.15, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 49.43 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5457.89, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CONCUSSION WITH MCC", "code_information": [ { "code": "088", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13660, "minimum": 13660.77, "maximum": 27125.6, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 13660.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 18442.04, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13934.02, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 13660.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 13660.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 13660.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 13660.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 13660.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 13660.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 15647.09 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13797.41, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26311.83 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 13660.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 13660.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 22198.75, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 17759, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 13660.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14480.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13660.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 13660.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 16392.92, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13660.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13660.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13660.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 26608.49 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13660.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13660.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18743.9 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 26657.5 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 23991.75 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 13660.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27125.6 } ] } ] }, { "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": 6156.11, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4735.47 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4806.5, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4972.24, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5209.02, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 5209.02, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4735.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4735.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6156.11, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4735.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4735.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4735.47, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC", "code_information": [ { "code": "025", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 44825, "minimum": 29250, "maximum": 89660.924, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 44825.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 60514.8, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 45722.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 44825.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 44825.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 44825.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 44825.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 44825.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 44825.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 52628.05 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 45274.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 83415.64 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 44825.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 44825.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 72841.89, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 58273.51, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 44825.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 47515.35, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 44825.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 29250, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 40500, "10th_percentile": 40500, "90th_percentile": 40500, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 44825.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 53790.94, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 44825.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 44825.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 44825.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 76609.13 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 44825.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 44825.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 51140.9 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 89660.92 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 80694.83 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 44825.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 85995.5 } ] } ] }, { "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": 12746.32, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9804.86 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9951.93, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 10295.1, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10785.35, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 10785.35, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9804.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9804.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12746.32, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 9804.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9804.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9804.86, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 20032.49, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15409.61 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15640.75, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 16180.09, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16950.57, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 16950.57, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15409.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15409.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20032.49, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 15409.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15409.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15409.61, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA - SOI : 1", "code_information": [ { "code": "9101", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 22594.97, "maximum": 29373.46, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22594.97 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22933.89, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 23724.72, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24854.47, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 24854.47, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 22594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29373.46, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 22594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 22594.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Conization Of Cervix - 57522 - OR36057522", "code_information": [ { "code": "57522", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15238.6, "discounted_cash": 4143, "minimum": 321.9798, "maximum": 13714.74, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6214.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 321.98 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4225.94, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 354.18 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 321.98 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 338.08 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6214.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4184.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5294.11, "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": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5386, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 354.18 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 321.98 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 354.18 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 321.98 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4391.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 321.98 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 4971.7, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 418.57 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 321.98 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5294.15, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 321.98 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5457.89, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CORONARY BYPASS W AMI OR COMPLEX PDX - SOI : 3", "code_information": [ { "code": "1653", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 46931.69, "maximum": 61011.2, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 46931.69 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 47635.67, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 49278.27, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 51624.86, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 51624.86, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 46931.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 46931.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 61011.2, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 46931.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 46931.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 46931.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 38633, "minimum": 17550, "maximum": 77142.668, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 38633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 52155.29, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 39406.27, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 38633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 38633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 38633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 38633.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 38633.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 38633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 45280.24 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 39019.94, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 70907.87 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 38633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 38633.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 62779.52, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 50223.62, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 38633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 40951.62, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 38633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 38633.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 46360.26, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 38633.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 38633.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 38633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 65728.41 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 38633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 38633.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 46661.7 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 77142.67 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 69428.4 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 38633.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 73100.9 } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS - SOI : 3", "code_information": [ { "code": "3463", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11432.12, "maximum": 14861.76, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11432.12 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11603.6, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 12003.73, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12575.33, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 12575.33, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11432.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11432.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14861.76, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 11432.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11432.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11432.12, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC", "code_information": [ { "code": "233", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 75050, "minimum": 50850, "maximum": 150763.344, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 75050.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 101318.08, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 76551.41, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 75050.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 75050.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 75050.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 75050.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 75050.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 75050.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 88493.19 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 75800.9, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 145788.48 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 75050.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 75050.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 121956.95, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 97565.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 75050.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 79553.42, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 75050.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 75050.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 90060.52, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 75050.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 75050.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 75050.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 135308.1 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 75050.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 75050.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 93935.1 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 150763.34 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 135687.01 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 75050.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 150297.4 } ] } ] }, { "description": "DISORDERS OF PERSONALITY & IMPULSE CONTROL - SOI : 1", "code_information": [ { "code": "7521", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2817.75, "maximum": 3663.08, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2817.75 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2860.02, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 2958.64, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3099.53, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 3099.53, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2817.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 2817.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3663.08, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 2817.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2817.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 2817.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS WITH MCC", "code_information": [ { "code": "545", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 24682, "minimum": 24682.5, "maximum": 48939.124, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 24682.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 33321.39, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 25176.15, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 24682.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 24682.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 24682.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 24682.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 24682.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 24682.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 28725.68 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 24929.33, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 47130.75 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 24682.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 24682.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 40109.08, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 32087.26, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 24682.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 26163.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 24682.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 24682.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 29619.01, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 24682.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 24682.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 24682.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 43252.24 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 24682.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 24682.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 29014.2 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 48939.12 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 44045.21 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 24682.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 48588.4 } ] } ] }, { "description": "CORONARY BYPASS WITH PTCA WITHOUT MCC", "code_information": [ { "code": "232", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 59612, "minimum": 34200, "maximum": 119554.472, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 59612.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 80477.27, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 60805.06, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 59612.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 59612.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 59612.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 59612.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 59612.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 59612.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 70174.6 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 60208.93, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 113937.07 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 59612.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 59612.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 96870.78, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 77496.63, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 59612.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 63189.57, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 59612.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 59612.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 71535.35, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 59612.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 59612.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 59612.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 103196.8 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 59612.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 59612.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 81165.4 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 119554.47 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 107599.02 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 59612.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 117460.9 } ] } ] }, { "description": "DISORDERS OF PERSONALITY & IMPULSE CONTROL - SOI : 4", "code_information": [ { "code": "7524", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 33313.64, "maximum": 43307.73, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33313.64 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33813.34, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 34979.32, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36645, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 36645, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33313.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 33313.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 43307.73, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 33313.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33313.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 33313.64, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 11607.99, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8929.22 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9063.16, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 9375.68, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9822.14, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 9822.14, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8929.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8929.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11607.99, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 8929.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8929.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8929.22, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CORONARY BYPASS WO AMI OR COMPLEX PDX - SOI : 4", "code_information": [ { "code": "1664", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 55046.75, "maximum": 71560.78, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55046.75 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55872.45, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 57799.09, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 60551.43, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 60551.43, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55046.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 55046.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 71560.78, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 55046.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55046.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 55046.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF THE BILIARY TRACT WITH CC", "code_information": [ { "code": "445", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11149, "minimum": 10515.7, "maximum": 21581.568, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 11149.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 15052.42, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11372.9, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11149.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 11149.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 11149.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 11149.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 11149.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 11149.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 12667.68 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11261.4, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20227.7 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11149.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 11149.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18118.65, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14494.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 11149.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11818.89, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11149.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 13500, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 36000, "10th_percentile": 36000, "90th_percentile": 36000, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 11149.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 13379.93, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11149.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11149.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11149.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 18853.89 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11149.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11149.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10515.7 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 21581.57 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 19423.41 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 11149.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20853.3 } ] } ] }, { "description": "Conz Of Cervix W/Scope Leep", "code_information": [ { "code": "57461", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14942, "discounted_cash": 4143, "minimum": 282.23, "maximum": 13447.8, "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5386, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 310.45 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 282.23 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 310.45 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 404.83 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4391.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 282.23 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 4971.7, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 366.9 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 282.23 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5294.15, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "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": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5457.89, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6214.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 282.23 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4225.94, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 310.45 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 282.23 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 296.34 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6214.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4184.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5294.11, "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": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "DIVERTICULITIS & DIVERTICULOSIS - SOI : 1", "code_information": [ { "code": "2441", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4359.13, "maximum": 5666.87, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4359.13 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4424.52, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4577.09, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4795.04, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4795.04, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4359.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4359.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5666.87, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4359.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4359.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4359.13, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC", "code_information": [ { "code": "235", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 57720, "minimum": 36450, "maximum": 115728.792, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 57720.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 77922.53, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 58874.81, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 57720.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 57720.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 57720.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 57720.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 57720.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 57720.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 67929.05 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 58297.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 109749.78 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 57720.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 57720.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 93795.63, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 75036.51, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 57720.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 61183.62, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 57720.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 57720.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 69264.47, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 57720.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 57720.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 57720.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 102017.13 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 57720.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 57720.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 72387.8 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 115728.79 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 104155.91 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 57720.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 113144.1 } ] } ] }, { "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": 56371, "minimum": 32850, "maximum": 113001.516, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 56371.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 76101.3, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 57498.73, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 56371.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 56371.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 56371.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 56371.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 56371.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 56371.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 66328.22 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 56935.01, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 106409.29 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 56371.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 56371.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 91603.41, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 73282.73, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 56371.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 59753.58, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 56371.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 56371.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 67645.6, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 56371.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 56371.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 56371.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 98342.8 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 56371.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 56371.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 75764.5 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 113001.52 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 101701.36 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 56371.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 109700.3 } ] } ] }, { "description": "CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC", "code_information": [ { "code": "236", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 41334, "minimum": 26100, "maximum": 82603.136, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 41334.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 55801.71, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 42161.29, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 41334.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 41334.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 41334.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 41334.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 41334.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 41334.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 48485.36 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 41747.95, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 76697.32 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 41334.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 41334.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 67168.73, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 53734.98, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 41334.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 43814.68, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 41334.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 41334.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 49601.52, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 41334.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 41334.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 41334.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 70107.07 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 41334.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 41334.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 58504.9 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 82603.14 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 74342.82 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 41334.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 79069.4 } ] } ] }, { "description": "CVA & PRECEREBRAL OCCLUSION W INFARCT - SOI : 2", "code_information": [ { "code": "0452", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8072.66, "maximum": 10494.46, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8072.66 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8193.75, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 8476.29, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8879.93, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 8879.93, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8072.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8072.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10494.46, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 8072.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8072.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8072.66, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CYSTIC FIBROSIS - PULMONARY DISEASE - SOI : 2", "code_information": [ { "code": "1312", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12532.5, "maximum": 16292.25, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12532.5 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12720.49, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 13159.13, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13785.75, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 13785.75, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12532.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12532.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16292.25, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 12532.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12532.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12532.5, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC", "code_information": [ { "code": "323", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 42686, "minimum": 20700, "maximum": 85336.328, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 42686.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 57626.9, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 43540.33, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 42686.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 42686.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 42686.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 42686.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 42686.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 42686.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 50089.66 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 43113.47, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 79444.65 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 42686.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 42686.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 69365.71, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 55492.57, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 42686.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 45247.8, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 42686.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 42686.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 51223.91, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 42686.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 42686.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 42686.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 71821.06 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 42686.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 42686.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 63309.7 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 85336.33 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 76802.7 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 42686.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 81901.7 } ] } ] }, { "description": "Cysto/Uretero W/Lithotripsy", "code_information": [ { "code": "52356", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 29492, "discounted_cash": 6862, "minimum": 354.06, "maximum": 26542.8, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10293.56, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 354.06 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6999.62, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 389.47 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 354.06 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 371.76 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 10293.56, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6930.99, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8768.87, "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": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8921.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 389.47 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 354.06 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 389.47 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 507.86 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7274.11, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 354.06 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 8234.84, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 460.28 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 354.06 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 354.06 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8768.94, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 354.06 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9040.14, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC", "code_information": [ { "code": "324", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 31211, "minimum": 10350, "maximum": 62137.72, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 31211.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 42135.21, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 31835.53, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 31211.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 31211.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 31211.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 31211.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 31211.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 31211.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 36472.83 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 31523.41, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 59593.79 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 31211.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 31211.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 50718.31, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 40574.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 31211.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 33083.98, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 31211.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 31211.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 37453.52, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 31211.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 31211.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 31211.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 51499.51 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 31211.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 31211.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 47722.2 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 62137.72 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 55923.95 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 31211.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 61436.9 } ] } ] }, { "description": "Cystoscopy And Treatment - 52224 - OR36052224", "code_information": [ { "code": "52224", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4052, "discounted_cash": 4511, "minimum": 220.55, "maximum": 4052, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 220.55 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 4052, "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": 242.61 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 220.55 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 231.58 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4052, "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": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 242.61 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 220.55 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 242.61 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 220.55 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 220.55 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 286.72 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 220.55 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 220.55 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 220.55 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "027", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 25084, "minimum": 7200, "maximum": 49751.588, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 25084.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 33863.94, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 25586.09, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 25084.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 25084.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 25084.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 25084.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 25084.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 25084.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 29202.57 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 25335.24, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 46028.44 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 25084.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 25084.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 40762.15, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 32609.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 25084.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 26589.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 25084.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 25084.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 30101.28, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 25084.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 25084.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 25084.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 42206.15 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 25084.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 25084.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 33941.1 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 49751.59 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 44776.43 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 25084.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 47452 } ] } ] }, { "description": "CYSTIC FIBROSIS - PULMONARY DISEASE - SOI : 3", "code_information": [ { "code": "1313", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 17564.8, "maximum": 22834.24, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17564.8 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17828.27, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 18443.04, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19321.28, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 19321.28, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17564.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 17564.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22834.24, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 17564.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17564.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 17564.8, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CCMCC", "code_information": [ { "code": "744", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20462, "minimum": 18247.2, "maximum": 40408.252, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 20462.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 27624.59, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 20871.95, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 20462.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 20462.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 20462.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 20462.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 20462.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 20462.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 23718.33 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 20667.33, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36445.23 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 20462.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 20462.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 33251.82, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 26601.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 20462.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21690.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 20462.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 20462.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 24555.19, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 20462.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20462.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20462.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 32656.03 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 20462.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20462.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18247.2 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 40408.25 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 36367.43 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 20462.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37572.4 } ] } ] }, { "description": "CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA", "code_information": [ { "code": "955", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 66133, "minimum": 39600, "maximum": 132737.292, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 66133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 89280.56, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 67456.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 66133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 66133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 66133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 66133.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 66133.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 66133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 77912.48 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 66795.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 127358.77 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 66133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 66133.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 107467.34, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 85973.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 66133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 70101.83, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 66133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 66133.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 79360.5, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 66133.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 66133.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 66133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 105653.29 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 66133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 66133.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 119819 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 132737.29 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 119463.56 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 66133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 131297.7 } ] } ] }, { "description": "Cysto W/Urtrl Cathj", "code_information": [ { "code": "52005", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 20000, "discounted_cash": 2675, "minimum": 217.8854, "maximum": 18000, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4013.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 217.89 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2728.92, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 239.68 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 217.89 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 228.78 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 4013.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2702.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3418.69, "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": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3478.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 239.68 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 217.89 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 239.68 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 217.89 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2835.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 217.89 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 3210.49, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 283.26 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 217.89 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 217.89 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3418.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 217.89 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3524.45, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK - SOI : 1", "code_information": [ { "code": "3041", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 21066.31, "maximum": 27386.2, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21066.31 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21382.3, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 22119.63, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23172.94, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 23172.94, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21066.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 21066.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27386.2, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 21066.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21066.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 21066.31, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA - SOI : 2", "code_information": [ { "code": "9102", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 22650.1, "maximum": 29445.13, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22650.1 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22989.85, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 23782.6, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24915.11, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 24915.11, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22650.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 22650.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29445.13, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 22650.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22650.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 22650.1, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Cystoscopy And Treatment - 52235 - OR36052235", "code_information": [ { "code": "52235", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 23342, "discounted_cash": 4511, "minimum": 640.83, "maximum": 21007.8, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6767.24, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 640.83 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4601.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 704.91 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 640.83 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 672.87 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6767.24, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4556.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5764.87, "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": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 704.91 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 640.83 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 704.91 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 640.83 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4782.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 640.83 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 5413.79, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 833.08 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 640.83 }, { "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": 640.83 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5764.91, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 640.83 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5943.21, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Cystoscopy And Treatment - 52276 - OR36052276", "code_information": [ { "code": "52276", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 22005.2, "discounted_cash": 2675, "minimum": 546.85, "maximum": 19804.68, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4013.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 546.85 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2728.92, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 601.54 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 546.85 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 574.19 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 4013.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2702.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3418.69, "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": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3478.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 601.54 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 546.85 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 601.54 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 546.85 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2835.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 546.85 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 3210.49, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 710.91 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 546.85 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 546.85 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3418.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 546.85 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3524.45, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Drainage Of Scrotum", "code_information": [ { "code": "54700", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9143.25, "discounted_cash": 2675, "minimum": 284.64, "maximum": 8228.925, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4013.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 284.64 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2728.92, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 313.1 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 284.64 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 298.87 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 4013.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2702.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3418.69, "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": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3478.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 313.1 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 284.64 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 313.1 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 284.64 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2835.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 284.64 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 3210.49, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 370.03 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 284.64 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 284.64 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3418.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 284.64 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3524.45, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CVA & PRECEREBRAL OCCLUSION W INFARCT - SOI : 3", "code_information": [ { "code": "0453", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10803.48, "maximum": 14044.52, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10803.48 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10965.53, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 11343.65, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11883.83, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 11883.83, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10803.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10803.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14044.52, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 10803.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10803.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10803.48, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEEP VEIN THROMBOPHLEBITIS WITHOUT CCMCC", "code_information": [ { "code": "295", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10494.2, "maximum": 15186.6, "payers_information": [ { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14731 }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13828.16 }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10494.2 }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15186.6 } ] } ] }, { "description": "DEFIBRILLATOR IMPLANTS- SOI : 4", "code_information": [ { "code": "1794", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 54992.69, "maximum": 71490.5, "payers_information": [ { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 57742.32, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 60491.96, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 60491.96, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54992.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 54992.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 71490.5, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 54992.69, "additional_payer_notes": "100% 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54992.69 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55817.58, "additional_payer_notes": "101.5% 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": 9229.34, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7099.49 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7205.98, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7454.46, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7809.44, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 7809.44, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7099.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7099.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9229.34, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 7099.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7099.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7099.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEFIBRILLATOR IMPLANTS- SOI : 3", "code_information": [ { "code": "1793", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 40597.59, "maximum": 52776.87, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 40597.59 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 41206.55, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 42627.47, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44657.35, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 44657.35, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 40597.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 40597.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 52776.87, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 40597.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 40597.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 40597.59, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS - SOI : 2", "code_information": [ { "code": "0422", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7420.7, "maximum": 9646.91, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7420.7 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7532.01, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7791.74, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8162.77, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 8162.77, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7420.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7420.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9646.91, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 7420.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7420.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7420.7, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 4392.1, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3378.54 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3429.22, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 3547.47, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3716.39, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 3716.39, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3378.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3378.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4392.1, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 3378.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3378.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3378.54, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CYSTIC FIBROSIS - PULMONARY DISEASE - SOI : 4", "code_information": [ { "code": "1314", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18877.2, "maximum": 24540.36, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18877.2 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19160.36, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 19821.06, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20764.92, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 20764.92, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18877.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18877.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24540.36, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 18877.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18877.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18877.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS - SOI : 3", "code_information": [ { "code": "0423", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10008.4, "maximum": 13010.92, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10008.4 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10158.53, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 10508.82, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11009.24, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 11009.24, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10008.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10008.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13010.92, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 10008.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10008.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10008.4, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC", "code_information": [ { "code": "056", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 23135, "minimum": 23135.4, "maximum": 48150, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 23135.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 31232.82, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 23598.11, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 23135.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 23135.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 23135.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 23135.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 23135.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 23135.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 26889.88 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 23366.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 46705.5 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 23135.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 23135.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 37595.06, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 30076.05, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 23135.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 24523.52, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 23135.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 23135.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 27762.5, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 23135.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 23135.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 23135.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 41531.31 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 23135.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 23135.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 28962.8 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 45811.53 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 41230.38 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 23135.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 48150 } ] } ] }, { "description": "EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC", "code_information": [ { "code": "147", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12877, "minimum": 12877.48, "maximum": 25073.98, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 12877.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 17384.6, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13135.05, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 12877.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 12877.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 12877.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 12877.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 12877.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 12877.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 14717.61 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13006.28, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23217.53 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 12877.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 12877.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20925.91, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16740.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 12877.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13650.15, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 12877.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 12877.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 15452.98, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 12877.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12877.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12877.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 21438.76 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12877.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12877.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14559.2 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 25073.98 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 22566.58 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 12877.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23935.6 } ] } ] }, { "description": "CYSTOSCOPY AND TREATMENT - 52290 - ", "code_information": [ { "code": "52290", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 20000, "discounted_cash": 2675, "minimum": 241.91, "maximum": 18000, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4013.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2728.92, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 266.1 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 254.01 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 4013.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2702.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3418.69, "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": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3478.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 266.1 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 266.1 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2835.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 3210.49, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 314.48 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "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": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3418.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "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": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3524.45, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 20000, "discounted_cash": 2675, "minimum": 241.91, "maximum": 18000, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4013.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2728.92, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 266.1 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 254.01 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 4013.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2702.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3418.69, "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": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3478.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 266.1 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 266.1 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2835.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 3210.49, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 314.48 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "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": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3418.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "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": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3524.45, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DENTAL DISEASES AND DISORDERS - SOI : 2", "code_information": [ { "code": "1142", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4606.13, "maximum": 5987.97, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4606.13 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4675.22, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4836.44, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5066.74, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 5066.74, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4606.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4606.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5987.97, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4606.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4606.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4606.13, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DENTAL DISEASES AND DISORDERS - SOI : 1", "code_information": [ { "code": "1141", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3289.49, "maximum": 4276.34, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3289.49 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3338.83, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 3453.96, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3618.44, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 3618.44, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3289.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3289.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4276.34, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 3289.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3289.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3289.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC", "code_information": [ { "code": "146", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21128, "minimum": 17062.1, "maximum": 44112, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 21128.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 28524.02, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 21551.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 21128.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 21128.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 21128.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 21128.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 21128.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 21128.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 24508.91 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 21340.19, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42788.64 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 21128.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 21128.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 34334.46, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 27467.57, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 21128.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22396.63, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 21128.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 21128.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 25354.68, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 21128.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21128.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 21128.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 36621.8 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 21128.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21128.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17062.1 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 41755.13 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 37579.62 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 21128.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 44112 } ] } ] }, { "description": "Cystourethroscopy", "code_information": [ { "code": "52000", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 21588, "discounted_cash": 892, "minimum": 124.43, "maximum": 19429.2, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1338.68, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 124.43 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 910.3, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 136.87 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 124.43 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.65 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 1338.68, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 901.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1140.39, "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": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1160.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 136.87 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 124.43 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 136.87 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 124.43 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 946, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 124.43 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 1070.94, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 161.76 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 124.43 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 124.43 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1140.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 124.43 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1175.67, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DENTAL DISEASES AND DISORDERS - SOI : 4", "code_information": [ { "code": "1144", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15815.63, "maximum": 20560.32, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15815.63 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16052.86, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 16606.41, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17397.19, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 17397.19, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15815.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15815.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20560.32, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 15815.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15815.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15815.63, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EAR, NOSE, MOUTH, THROAT, CRANIALFACIAL MALIGNANCIES - SOI : 1", "code_information": [ { "code": "1101", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6412.54, "maximum": 8336.3, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6412.54 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6508.73, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 6733.17, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7053.79, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 7053.79, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6412.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6412.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8336.3, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 6412.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6412.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6412.54, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EAR, NOSE, MOUTH, THROAT, CRANIALFACIAL MALIGNANCIES - SOI : 4", "code_information": [ { "code": "1104", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 17487.41, "maximum": 22733.63, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17487.41 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17749.72, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 18361.78, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19236.15, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 19236.15, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17487.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 17487.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22733.63, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 17487.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17487.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 17487.41, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EATING DISORDERS - SOI : 2", "code_information": [ { "code": "7592", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8406.59, "maximum": 10928.57, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8406.59 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8532.69, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 8826.92, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9247.25, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 9247.25, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8406.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8406.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10928.57, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 8406.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8406.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8406.59, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CCMCC", "code_information": [ { "code": "745", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11570, "minimum": 5206.97, "maximum": 22431.5, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 11570.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 15619.99, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11801.81, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11570.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 11570.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 11570.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 11570.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 11570.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 11570.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 13166.56 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11686.1, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19114.14 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11570.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 11570.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18801.84, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 15041.47, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 11570.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12264.62, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11570.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 11570.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 13884.43, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11570.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11570.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11570.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 17970.88 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11570.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11570.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5206.97 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 22431.5 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 20188.35 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 11570.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19705.3 } ] } ] }, { "description": "ELECTIVE KNEE JOINT REPLACEMENT- SOI : 4", "code_information": [ { "code": "3264", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 25927.93, "maximum": 33706.31, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25927.93 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26316.85, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 27224.33, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28520.72, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 28520.72, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25927.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 25927.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33706.31, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 25927.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25927.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 25927.93, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEEP VEIN THROMBOPHLEBITIS WITH CCMCC", "code_information": [ { "code": "294", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15300, "maximum": 23612.6, "payers_information": [ { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22904.22 }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 18973.6 }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16316.4 }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23612.6 } ] } ] }, { "description": "ENDOCRINE DISORDERS WITH MCC", "code_information": [ { "code": "643", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16531, "minimum": 16531.5, "maximum": 32461.092, "payers_information": [ { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 28539.33 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16531.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16531.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17746.8 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 32461.09 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 29214.98 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 16531.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31867.3 }, { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 16531.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 22317.59, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 16862.13, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 16531.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 16531.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 16531.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 16531.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 16531.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 16531.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 19053.61 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16696.82, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30911.28 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 16531.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 16531.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 26863.77, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 21491.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 16531.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17523.39, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 16531.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 16531.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 19837.86, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 16531.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16531.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16531.5, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "DEFIBRILLATOR IMPLANTS- SOI : 1", "code_information": [ { "code": "1791", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 28107.49, "maximum": 36539.74, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28107.49 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28529.1, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 29512.86, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 30918.24, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 30918.24, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28107.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 28107.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36539.74, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 28107.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28107.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 28107.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS - SOI : 1", "code_information": [ { "code": "0421", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5906.88, "maximum": 7678.94, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5906.88 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5995.48, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 6202.22, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6497.57, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 6497.57, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5906.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5906.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7678.94, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 5906.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5906.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5906.88, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS - SOI : 4", "code_information": [ { "code": "0424", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18420.3, "maximum": 23946.39, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18420.3 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18696.6, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 19341.31, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20262.33, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 20262.33, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18420.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18420.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23946.39, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 18420.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18420.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18420.3, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DENTAL AND ORAL DISEASES WITH CC", "code_information": [ { "code": "158", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9349, "minimum": 9349.23, "maximum": 18086.3, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 9349.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 12621.46, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9536.21, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9349.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 9349.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 9349.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 9349.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 9349.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 9349.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 10530.94 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9442.72, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17543.71 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9349.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9349.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15192.5, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12154, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 9349.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9910.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9349.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 9349.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 11219.08, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9349.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9349.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9349.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 16281.17 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9349.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9349.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9823.83 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 17941.26 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 16147.13 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 9349.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18086.3 } ] } ] }, { "description": "DENTAL AND ORAL DISEASES WITH MCC", "code_information": [ { "code": "157", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17221, "minimum": 17221.2, "maximum": 33855.296, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 17221.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 23248.62, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 17565.62, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 17221.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 17221.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 17221.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 17221.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 17221.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 17221.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 19871.96 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 17393.41, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30542 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 17221.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 17221.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 27984.45, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 22387.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 17221.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18254.47, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 17221.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 17221.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 20665.44, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 17221.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17221.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17221.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 29613.17 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 17221.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17221.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19347.2 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 33855.3 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 30469.77 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 17221.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31486.6 } ] } ] }, { "description": "DIABETES - SOI : 3", "code_information": [ { "code": "4203", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7786.43, "maximum": 10122.36, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7786.43 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7903.23, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 8175.75, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8565.07, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 8565.07, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7786.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7786.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10122.36, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 7786.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7786.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7786.43, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DENTAL DISEASES AND DISORDERS - SOI : 3", "code_information": [ { "code": "1143", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6926.69, "maximum": 9004.7, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6926.69 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7030.59, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7273.02, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7619.36, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 7619.36, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6926.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6926.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9004.7, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 6926.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6926.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6926.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIABETES - SOI : 4", "code_information": [ { "code": "4204", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14323.01, "maximum": 18619.91, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14323.01 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14537.86, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 15039.16, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15755.31, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 15755.31, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14323.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14323.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18619.91, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 14323.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14323.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14323.01, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIABETES - SOI : 2", "code_information": [ { "code": "4202", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5392.73, "maximum": 7010.55, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5392.73 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5473.62, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 5662.37, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5932, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 5932, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5392.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5392.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7010.55, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 5392.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5392.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5392.73, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Destruction Penis Lesion(S)", "code_information": [ { "code": "54065", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4052, "discounted_cash": 2640, "minimum": 263.48, "maximum": 3961.08, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3961.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 263.48 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2693.53, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 289.83 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 263.48 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "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": 276.65 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3961.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2667.13, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3374.36, "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": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3432.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 289.83 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 263.48 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 289.83 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 263.48 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2799.16, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 263.48 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 3168.86, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 342.52 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 263.48 }, { "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": 263.48 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3374.39, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 263.48 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3478.75, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DIABETES WITH CC", "code_information": [ { "code": "638", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9216, "minimum": 7580.64, "maximum": 17673.064, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 9216.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 12442.37, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9400.9, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9216.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 9216.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 9216.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 9216.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 9216.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 9216.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 10373.52 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9308.74, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17107.21 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9216.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9216.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14976.93, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11981.54, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 9216.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9769.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9216.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 13500, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 22500, "10th_percentile": 22500, "90th_percentile": 40500, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 9216.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 11059.88, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9216.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9216.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9216.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 15602.86 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9216.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9216.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7580.64 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 17673.06 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 15905.76 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 9216.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17636.3 } ] } ] }, { "description": "Diagnostic Colonoscopy", "code_information": [ { "code": "45378", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14942, "discounted_cash": 1190, "minimum": 423.4779, "maximum": 13447.8, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1785.33, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 423.48 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1214.02, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 465.83 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 423.48 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 444.65 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise 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 Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 1785.33, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1202.12, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1520.89, "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": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1547.29, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 465.83 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 423.48 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 465.83 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 423.48 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1261.63, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 423.48 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 1428.26, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 550.52 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 423.48 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1520.9, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 423.48 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1567.94, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DIABETES WITHOUT CCMCC", "code_information": [ { "code": "639", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6534, "minimum": 5489.47, "maximum": 12250.064, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 6534.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 8820.97, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6664.73, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6534.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 6534.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 6534.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 6534.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 6534.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 6534.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 7190.39 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6599.39, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11687.14 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6534.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6534.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 10617.83, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 8494.27, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 6534.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6926.09, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6534.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 9000, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 18000, "10th_percentile": 18000, "90th_percentile": 18000, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 6534.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 7840.86, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6534.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6534.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6534.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 10799.18 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6534.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6534.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5489.47 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 12250.06 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 11025.06 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 6534.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12048.6 } ] } ] }, { "description": "DIGESTIVE MALIGNANCY - SOI : 3", "code_information": [ { "code": "2403", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10169.54, "maximum": 13220.4, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10169.54 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10322.08, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 10678.02, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11186.49, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 11186.49, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10169.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10169.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13220.4, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 10169.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10169.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10169.54, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIGESTIVE MALIGNANCY - SOI : 4", "code_information": [ { "code": "2404", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15872.88, "maximum": 20634.74, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15872.88 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16110.97, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 16666.52, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17460.17, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 17460.17, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15872.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15872.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20634.74, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 15872.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15872.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15872.88, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIGESTIVE MALIGNANCY WITHOUT CCMCC", "code_information": [ { "code": "376", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9490, "minimum": 9490.68, "maximum": 18227.196, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 9490.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 12812.42, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9680.49, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9490.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 9490.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 9490.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 9490.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 9490.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 9490.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 10698.77 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9585.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16469.34 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9490.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9490.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15422.36, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12337.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 9490.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10060.12, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9490.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 9490.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 11388.82, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9490.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9490.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9490.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 15464.08 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9490.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9490.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10633 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 18227.2 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 16404.48 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 9490.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16978.7 } ] } ] }, { "description": "Exc Back Tum Deep 5 Cm/>", "code_information": [ { "code": "21933", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18929.7, "discounted_cash": 3717, "minimum": 609.08, "maximum": 17036.73, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 609.08 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 669.99 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 609.08 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 639.53 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.46, "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": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 669.99 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 609.08 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 669.99 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 873.66 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 609.08 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 4461.16, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 791.8 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 609.08 }, { "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": 609.08 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 609.08 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES - SOI : 1", "code_information": [ { "code": "5171", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6167.66, "maximum": 8017.96, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6167.66 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6260.17, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 6476.04, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6784.43, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 6784.43, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6167.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6167.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8017.96, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 6167.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6167.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6167.66, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Dilation And Curettage", "code_information": [ { "code": "58120", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4052, "discounted_cash": 4143, "minimum": 319.7995, "maximum": 4052, "payers_information": [ { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 319.8 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 4052, "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": 351.78 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 319.8 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 335.79 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4052, "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": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 351.78 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 319.8 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 351.78 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 319.8 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 319.8 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 415.74 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 319.8 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 319.8 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 319.8 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4052, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "Exc Face Tum Deep 2 Cm/>", "code_information": [ { "code": "21014", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14942, "discounted_cash": 3717, "minimum": 432.61, "maximum": 13447.8, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 432.61 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 475.87 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 432.61 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 454.24 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.46, "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": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 475.87 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 432.61 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 475.87 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 620.54 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 432.61 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 4461.16, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 562.39 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 432.61 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "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": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DIABETES - SOI : 1", "code_information": [ { "code": "4201", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4059.12, "maximum": 5276.86, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4059.12 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4120.01, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4262.08, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4465.03, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4465.03, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4059.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4059.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5276.86, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4059.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4059.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4059.12, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES - SOI : 4", "code_information": [ { "code": "5174", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 21946.19, "maximum": 28530.05, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21946.19 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22275.38, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 23043.5, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24140.81, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 24140.81, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21946.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 21946.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28530.05, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 21946.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21946.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 21946.19, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC", "code_information": [ { "code": "442", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9890, "minimum": 9890.62, "maximum": 19035.716, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 9890.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 13352.34, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10088.43, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9890.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 9890.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 9890.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 9890.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 9890.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 9890.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 11173.35 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9989.53, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18021.15 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9890.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9890.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16072.26, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12857.81, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 9890.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10484.06, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9890.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 9890.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 11868.74, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9890.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9890.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9890.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 16506.7 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9890.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9890.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11163.3 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 19035.72 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 17132.14 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 9890.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18578.5 } ] } ] }, { "description": "Exc H-F-Nk-Sp B9+Marg >4 Cm", "code_information": [ { "code": "11426", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15294.7, "discounted_cash": 3717, "minimum": 344.44, "maximum": 13765.23, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 344.44 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 378.88 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 344.44 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 361.66 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.46, "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": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 378.88 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 344.44 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 378.88 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 344.44 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 344.44 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 4461.16, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 447.77 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 344.44 }, { "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": 344.44 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 344.44 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DIABETES WITH MCC", "code_information": [ { "code": "637", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14488, "minimum": 12800.8, "maximum": 28331.724, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 14488.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 19560.07, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 14778.68, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 14488.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 14488.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 14488.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 14488.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 14488.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 14488.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 16629.8 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 14633.79, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27162.33 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 14488.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 14488.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 23544.53, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 18835.62, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 14488.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15358.23, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 14488.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 18000, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 9000, "10th_percentile": 9000, "90th_percentile": 18000, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 14488.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 17386.73, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 14488.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14488.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14488.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 25142.57 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14488.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14488.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12800.8 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 28331.72 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 25498.55 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 14488.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28002.4 } ] } ] }, { "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": 7299, "minimum": 7189.22, "maximum": 13798.084, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 7299.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 9854.72, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7445.79, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7299.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 7299.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 7299.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 7299.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 7299.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 7299.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8099.03 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7372.79, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13106.45 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7299.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7299.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11862.16, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9489.73, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 7299.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7737.78, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7299.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 7299.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 8759.75, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7299.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7299.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7299.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12398.67 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7299.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7299.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7189.22 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 13798.08 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 12418.28 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 7299.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13511.8 } ] } ] }, { "description": "Exc Hip/Pelv Tum Deep 5 Cm/>", "code_information": [ { "code": "27045", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14942, "discounted_cash": 3717, "minimum": 611.69, "maximum": 13447.8, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 611.69 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 672.86 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 611.69 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 642.27 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.46, "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": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 672.86 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 611.69 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 672.86 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 877.41 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 611.69 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 4461.16, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 795.2 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 611.69 }, { "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": 611.69 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 611.69 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY - SOI : 2", "code_information": [ { "code": "2822", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5998.05, "maximum": 7797.47, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5998.05 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6088.02, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 6297.95, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6597.86, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 6597.86, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5998.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5998.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7797.47, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 5998.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5998.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5998.05, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXC HIPPELVIS LES SC < 3 CM", "code_information": [ { "code": "27047", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1918.23, "discounted_cash": 3717, "minimum": 575.469, "maximum": 1918.23, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1918.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1918.23, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 736.95 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1918.23, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1918.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1918.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 1918.23, "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": 810.65 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 736.95 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1918.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1918.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1918.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 773.8 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1918.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 1918.23, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1918.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1918.23, "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": 1918.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 1918.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1918.23, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 810.65 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 736.95 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 810.65 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 1918.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 736.95 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1918.23, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 736.95 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1918.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 1918.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 1918.23, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1918.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 958.04 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 736.95 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1918.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 736.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1918.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1918.23, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1918.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 736.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1918.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1918.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1918.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1918.23, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CCMCC", "code_information": [ { "code": "440", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6536, "minimum": 6536, "maximum": 12254.008, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 6536, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 8823.6, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6666.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6536, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 6536, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 6536, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 6536, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 6536, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 6536, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 7192.71 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6601.36, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11472.58 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6536, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6536, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 10621, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 8496.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 6536, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6928.16, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6536, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 10350, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 9000, "10th_percentile": 9000, "90th_percentile": 9000, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 6536, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 7843.2, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6536, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6536, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6536, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 10679.48 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6536, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6536, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6856.45 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 12254.01 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 11028.61 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 6536, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11827.4 } ] } ] }, { "description": "Exc Neck Les Sc < 3 Cm", "code_information": [ { "code": "21555", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 34888, "discounted_cash": 2113, "minimum": 364.067, "maximum": 31399.2, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 474.74 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 364.07 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 474.74 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 498.48 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.08, "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": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 522.21 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 474.74 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 522.21 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 474.74 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 474.74 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 2536.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 617.16 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 474.74 }, { "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": 474.74 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 474.74 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DISORDERS OF PERSONALITY & IMPULSE CONTROL - SOI : 3", "code_information": [ { "code": "7523", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7618.94, "maximum": 9904.62, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7618.94 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7733.22, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7999.89, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8380.83, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 8380.83, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7618.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7618.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9904.62, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 7618.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7618.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7618.94, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXC NECK LES SC 3 CM>", "code_information": [ { "code": "21552", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5000, "discounted_cash": 3717, "minimum": 370.07, "maximum": 5000, "payers_information": [ { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 370.07 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5000, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 370.07 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 407.08 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 370.07 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 388.57 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5000, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.46, "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": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 407.08 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 370.07 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 407.08 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 530.83 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 370.07 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 4461.16, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 481.09 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 370.07 }, { "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": 370.07 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 5000, "discounted_cash": 3717, "minimum": 370.07, "maximum": 5000, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5000, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 370.07 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 407.08 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 370.07 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 388.57 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5000, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.46, "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": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 407.08 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 370.07 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 407.08 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 530.83 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 370.07 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 4461.16, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 481.09 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 370.07 }, { "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": 370.07 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 370.07 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DIGESTIVE MALIGNANCY - SOI : 1", "code_information": [ { "code": "2401", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5584.61, "maximum": 7259.99, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5584.61 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5668.38, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 5863.84, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6143.07, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 6143.07, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5584.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5584.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7259.99, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 5584.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5584.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5584.61, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF PERSONALITY AND IMPULSE CONTROL", "code_information": [ { "code": "883", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19654, "minimum": 6960, "maximum": 38775.436, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 19655, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 26534.22, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 20048.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 19655, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 19655, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 19655, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 19654.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 19654.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 19655, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 22759.92 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 19851.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34578.17 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 19655, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 19654.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 31939.34, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 25551.47, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 19655, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20834.3, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 19655, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 19654.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 23585.98, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 19654.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19654.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19655, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 32534.59 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19655, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19654.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14674.1 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 38775.44 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 34897.89 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 19655, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35647.6 } ] } ] }, { "description": "Exc Neck Tum Deep < 5 Cm", "code_information": [ { "code": "21556", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16892.7, "discounted_cash": 3717, "minimum": 457.017, "maximum": 15203.43, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 572.48 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 457.02 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 572.48 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 601.1 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.46, "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": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 629.73 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 572.48 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 629.73 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 572.48 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 572.48 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 4461.16, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 744.22 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 572.48 }, { "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": 572.48 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 572.48 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DIGESTIVE MALIGNANCY WITH CC", "code_information": [ { "code": "375", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12273, "minimum": 12273.67, "maximum": 23853.312, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 12273.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 16569.45, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 12519.17, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 12273.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 12273.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 12273.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 12273.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 12273.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 12273.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 14001.12 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12396.44, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22917.22 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 12273.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 12273.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 19944.71, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 15955.77, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 12273.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13010.12, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 12273.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 12273.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 14728.4, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 12273.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12273.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12273.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 20788.21 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12273.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12273.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 13736.8 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 23853.31 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 21467.98 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 12273.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23626 } ] } ] }, { "description": "DISORDERS OF GALLBLADDER & BILIARY TRACT - SOI : 1", "code_information": [ { "code": "2841", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5267.64, "maximum": 6847.93, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5267.64 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5346.65, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 5531.02, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5794.4, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 5794.4, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5267.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5267.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6847.93, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 5267.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5267.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5267.64, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIVERTICULITIS & DIVERTICULOSIS - SOI : 4", "code_information": [ { "code": "2444", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15668.28, "maximum": 20368.76, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15668.28 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15903.3, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 16451.69, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17235.11, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 17235.11, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15668.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15668.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20368.76, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 15668.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15668.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15668.28, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc tr-ext b9+marg 0.5 cm<", "code_information": [ { "code": "11400", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16000, "discounted_cash": 906, "minimum": 83.31, "maximum": 14400, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1359.47, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 83.31 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 924.44, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 91.64 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 83.31 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 87.48 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 1359.47, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 915.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1158.1, "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": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1178.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 91.64 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 83.31 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 91.64 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 83.31 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 960.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 83.31 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 1087.57, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 108.3 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 83.31 }, { "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": 83.31 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1158.11, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 83.31 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 16000, "discounted_cash": 906, "minimum": 83.31, "maximum": 14400, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1359.47, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 83.31 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 924.44, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 91.64 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 83.31 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 87.48 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 1359.47, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 915.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1158.1, "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": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1178.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 91.64 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 83.31 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 91.64 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 83.31 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 960.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 83.31 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 1087.57, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 108.3 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 83.31 }, { "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": 83.31 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1158.11, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 83.31 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DIGESTIVE MALIGNANCY WITH MCC", "code_information": [ { "code": "374", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21336, "minimum": 21336.67, "maximum": 42175.164, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 21336.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 28804.5, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 21763.43, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 21336.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 21336.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 21336.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 21336.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 21336.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 21336.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 24755.45 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 21550.07, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39381.03 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 21336.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 21336.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 34672.09, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 27737.67, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 21336.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22616.9, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 21336.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 25200, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 45000, "10th_percentile": 45000, "90th_percentile": 45000, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 21336.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 25604, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 21336.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21336.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 21336.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 36413.62 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 21336.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21336.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 26008.5 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 42175.16 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 37957.65 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 21336.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40599 } ] } ] }, { "description": "DISORDERS OF GALLBLADDER & BILIARY TRACT - SOI : 2", "code_information": [ { "code": "2842", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7392.08, "maximum": 9609.7, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7392.08 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7502.96, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7761.68, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8131.29, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 8131.29, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7392.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7392.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9609.7, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 7392.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7392.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7392.08, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA - SOI : 3", "code_information": [ { "code": "9113", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 29241.8, "maximum": 38014.34, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29241.8 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29680.43, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 30703.89, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32165.98, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 32165.98, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29241.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 29241.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38014.34, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 29241.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29241.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 29241.8, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES - SOI : 2", "code_information": [ { "code": "5172", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8522.14, "maximum": 11078.78, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8522.14 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8649.97, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 8948.25, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9374.35, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 9374.35, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8522.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8522.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11078.78, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 8522.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8522.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8522.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF GALLBLADDER & BILIARY TRACT - SOI : 4", "code_information": [ { "code": "2844", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 17059.13, "maximum": 22176.87, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17059.13 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17315.02, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 17912.09, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18765.04, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 18765.04, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17059.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 17059.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22176.87, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 17059.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17059.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 17059.13, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 36605.89, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28158.38 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28580.76, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 29566.3, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 30974.22, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 30974.22, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28158.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 28158.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36605.89, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 28158.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28158.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 28158.38, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 208740, "minimum": 108000, "maximum": 457272.87, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 208740, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 281799.39, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 212914.8, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 208740, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 208740, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 208740, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 208740.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 208740.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 208740, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 247132.04 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 210827.4, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 442468.41 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 208740, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 208740.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 339202.97, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 271362.38, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 208740, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 221264.4, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 208740, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 208740.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 250488.35, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 208740.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 208740.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 208740, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 457272.87 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 208740, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 208740.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 315199 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 421031.86 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 378928.67 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 208740, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 456153 } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY - SOI : 3", "code_information": [ { "code": "2823", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9386.13, "maximum": 12201.97, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9386.13 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9526.92, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 9855.44, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10324.74, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 10324.74, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9386.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9386.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12201.97, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 9386.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9386.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9386.13, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 50540.17, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38877.05 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39460.21, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 40820.9, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42764.76, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 42764.76, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38877.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 38877.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 50540.17, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 38877.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38877.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 38877.05, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE THIRD DEGREE BURNS WITHOUT SKIN GRAFT- SOI : 3", "code_information": [ { "code": "8433", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11688.66, "maximum": 15195.26, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11688.66 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11863.99, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 12273.09, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12857.53, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 12857.53, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11688.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11688.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15195.26, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 11688.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11688.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11688.66, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY - SOI : 4", "code_information": [ { "code": "2824", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 20005.15, "maximum": 26006.7, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20005.15 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20305.23, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 21005.41, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22005.67, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 22005.67, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20005.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 20005.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26006.7, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 20005.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20005.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 20005.15, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 48031.97, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36947.67 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 37501.89, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 38795.05, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 40642.44, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 40642.44, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36947.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 36947.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48031.97, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 36947.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36947.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 36947.67, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE THIRD DEGREE BURNS WITHOUT SKIN GRAFT- SOI : 4", "code_information": [ { "code": "8434", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16967.96, "maximum": 22058.35, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16967.96 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17222.48, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 17816.36, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18664.76, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 18664.76, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16967.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16967.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22058.35, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 16967.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16967.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16967.96, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC", "code_information": [ { "code": "438", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16376, "minimum": 16376.46, "maximum": 32147.544, "payers_information": [ { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17359.09, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 16376.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 16376.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 19651.75, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 16376.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16376.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16376.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 28950.48 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16376.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16376.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19542.3 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 32147.54 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 28932.79 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 16376.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31990.4 }, { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 16376.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 22108.22, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 16704.03, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 16376.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 16376.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 16376.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 16376.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 16376.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 16376.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 18869.57 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16540.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31030.69 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 16376.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 16376.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 26611.75, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 21289.4, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 16376.5, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "EXTERNAL HEART ASSIST SYSTEMS- SOI : 1", "code_information": [ { "code": "1781", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 39720.89, "maximum": 51637.16, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39720.89 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 40316.7, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 41706.93, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 43692.98, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 43692.98, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39720.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 39720.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 51637.16, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 39720.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39720.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 39720.89, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF GALLBLADDER & BILIARY TRACT - SOI : 3", "code_information": [ { "code": "2843", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9985.08, "maximum": 12980.6, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9985.08 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10134.86, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 10484.33, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10983.59, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 10983.59, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9985.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9985.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12980.6, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 9985.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9985.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9985.08, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF PERSONALITY & IMPULSE CONTROL - SOI : 2", "code_information": [ { "code": "7522", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3671.13, "maximum": 4772.47, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3671.13 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3726.2, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 3854.69, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4038.24, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4038.24, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3671.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3671.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4772.47, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 3671.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3671.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3671.13, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTRACRANIAL PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "039", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11941, "minimum": 5400, "maximum": 23180.86, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 11941, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 16120.39, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 12179.82, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11941, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 11941, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 11941, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 11941.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 11941.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 11941, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 13606.41 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12060.41, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21229.23 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11941, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 11941.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 19404.17, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 15523.34, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 11941, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12657.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11941, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 11941.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 14329.24, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11941.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11941.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11941, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 19794.16 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11941, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11941.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19597.4 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 23180.86 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 20862.77 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 11941, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21885.8 } ] } ] }, { "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": 17981, "minimum": 17981.09, "maximum": 36349.5, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 17981.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 24274.47, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 18340.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 17981.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 17981.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 17981.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 17981.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 17981.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 17981.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 20773.65 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18160.91, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35259.02 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 17981.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 17981.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 29219.27, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 23375.42, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 17981.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19059.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 17981.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 17981.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 21577.31, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 17981.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17981.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17981.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 31715.76 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 17981.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17981.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 21647.9 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 35391.48 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 31852.34 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 17981.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36349.5 } ] } ] }, { "description": "DISORDERS OF THE BILIARY TRACT WITH MCC", "code_information": [ { "code": "444", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16773, "minimum": 16029.1, "maximum": 32950.148, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 16773.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 22644.18, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 17108.97, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 16773.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 16773.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 16773.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 16773.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 16773.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 16773.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 19340.67 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16941.24, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31416.75 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 16773.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 16773.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 27256.89, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 21805.51, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 16773.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17779.91, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 16773.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 16773.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 20128.16, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 16773.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16773.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16773.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 28332.89 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16773.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16773.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16029.1 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 32950.15 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 29655.13 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 16773.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32388.4 } ] } ] }, { "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": 2801.73, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2155.18 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2187.51, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 2262.94, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2370.7, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 2370.7, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2155.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 2155.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2801.73, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 2155.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2155.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 2155.18, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EYE INFECTIONS AND OTHER EYE DISORDERS - SOI : 3", "code_information": [ { "code": "0823", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8121.43, "maximum": 10557.86, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8121.43 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8243.25, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 8527.5, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8933.57, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 8933.57, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8121.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8121.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10557.86, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 8121.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8121.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8121.43, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY - SOI : 1", "code_information": [ { "code": "2821", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4490.58, "maximum": 5837.75, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4490.58 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4557.94, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4715.11, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4939.64, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4939.64, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4490.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4490.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5837.75, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4490.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4490.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4490.58, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIVERTICULITIS & DIVERTICULOSIS - SOI : 2", "code_information": [ { "code": "2442", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5831.61, "maximum": 7581.09, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5831.61 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5919.08, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 6123.19, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6414.77, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 6414.77, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5831.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5831.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7581.09, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 5831.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5831.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5831.61, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 14298.1, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10998.54 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11163.52, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 11548.47, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12098.39, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 12098.39, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10998.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10998.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14298.1, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 10998.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10998.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10998.54, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EYE INFECTIONS AND OTHER EYE DISORDERS - SOI : 4", "code_information": [ { "code": "0824", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14031.48, "maximum": 18240.92, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14031.48 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14241.95, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 14733.05, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15434.63, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 15434.63, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14031.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14031.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18240.92, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 14031.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14031.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14031.48, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC", "code_information": [ { "code": "439", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8680, "minimum": 8680.07, "maximum": 16588.464, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 8680.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 11718.09, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8853.67, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8680.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 8680.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 8680.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 8680.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 8680.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8680.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 9736.89 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8766.87, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16044.09 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8680.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8680.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14105.11, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11284.09, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 8680.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9200.87, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8680.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 8680.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 10416.08, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8680.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8680.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8680.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 14836.08 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8680.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8680.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9122.38 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 16588.46 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 14929.62 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8680.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16540.3 } ] } ] }, { "description": "DIVERTICULITIS & DIVERTICULOSIS - SOI : 3", "code_information": [ { "code": "2443", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8730.98, "maximum": 11350.27, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8730.98 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8861.94, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 9167.53, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9604.08, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 9604.08, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8730.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8730.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11350.27, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 8730.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8730.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8730.98, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EAR, NOSE, MOUTH, THROAT, CRANIALFACIAL MALIGNANCIES - SOI : 3", "code_information": [ { "code": "1103", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10282.97, "maximum": 13367.86, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10282.97 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10437.21, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 10797.12, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11311.27, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 11311.27, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10282.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10282.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13367.86, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 10282.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10282.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10282.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 18400.8, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14154.46 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14366.78, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 14862.18, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15569.91, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 15569.91, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18400.8, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 14154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14154.46, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF THE BILIARY TRACT WITHOUT CCMCC", "code_information": [ { "code": "446", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8544, "minimum": 8017.55, "maximum": 16314.356, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 8544.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 11535.05, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8715.37, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8544.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 8544.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 8544.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 8544.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 8544.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8544.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 9576 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8629.92, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14870.97 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8544.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8544.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13884.78, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11107.82, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 8544.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9057.15, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8544.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 8544.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 10253.38, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8544.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8544.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8544.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13904.49 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8544.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8544.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8017.55 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 16314.36 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 14682.92 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8544.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15330.9 } ] } ] }, { "description": "ELECTIVE HIP JOINT REPLACEMENT- SOI : 2", "code_information": [ { "code": "3242", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13814.16, "maximum": 17958.41, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13814.16 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14021.37, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 14504.87, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15195.58, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 15195.58, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13814.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13814.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17958.41, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 13814.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13814.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13814.16, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Division Of Fallopian Tube", "code_information": [ { "code": "58600", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18879.5, "discounted_cash": 4143, "minimum": 1055.384, "maximum": 16991.55, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6214.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1086.57 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4225.94, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 1055.38 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1086.57 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 1140.9 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6214.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4184.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5294.11, "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": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5386, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1195.23 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 1086.57 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 1195.23 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1086.57 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4391.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1086.57 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 4971.7, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1412.54 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 1086.57 }, { "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": 1086.57 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5294.15, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1086.57 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5457.89, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM INFECTIONS - SOI : 1", "code_information": [ { "code": "5311", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4150.29, "maximum": 5395.38, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4150.29 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4212.54, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4357.8, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4565.32, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4565.32, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4150.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4150.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5395.38, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4150.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4150.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4150.29, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 42380.26, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32600.2 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33089.2, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 34230.21, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35860.22, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 35860.22, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32600.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 32600.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42380.26, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 32600.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32600.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 32600.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC", "code_information": [ { "code": "266", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 60254, "minimum": 11700, "maximum": 120852.048, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 60254.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 81343.76, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 61459.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 60254.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 60254.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 60254.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 60254.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 60254.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 60254.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 70936.23 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 60857.15, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 111738.08 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 60254.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 60254.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 97913.79, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 78331.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 60254.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 63869.88, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 60254.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 60254.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 72305.57, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 60254.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 60254.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 60254.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 108357.85 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 60254.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 60254.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 50280.2 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 120852.05 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 108766.84 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 60254.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 115193.9 } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM INFECTIONS - SOI : 2", "code_information": [ { "code": "5312", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5424.53, "maximum": 7051.89, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5424.53 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5505.9, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 5695.76, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5966.98, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 5966.98, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5424.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5424.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7051.89, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 5424.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5424.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5424.53, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 96259.62, "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 81450.45, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 74045.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 74045.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 96259.62, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 74045.86, "additional_payer_notes": "100% 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 74045.86 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 75156.55, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 77748.15, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 81450.45, "additional_payer_notes": "110% 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": 12513.42, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9625.71 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9770.1, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 10107, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10588.28, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 10588.28, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9625.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9625.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12513.42, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 9625.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9625.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9625.71, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 70754.57, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54426.59 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55242.99, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 57147.92, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 59869.25, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 59869.25, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54426.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 54426.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 70754.57, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 54426.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54426.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 54426.59, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM MALIGNANCY - SOI : 4", "code_information": [ { "code": "5304", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14427.96, "maximum": 18756.35, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14427.96 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14644.38, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 15149.36, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15870.76, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 15870.76, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14427.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14427.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18756.35, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 14427.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14427.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14427.96, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 64262.2, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 49432.46 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 50173.95, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 51904.08, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54375.71, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 54375.71, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 49432.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 49432.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 64262.2, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 49432.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 49432.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 49432.46, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 7126.31, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5481.78 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5564.01, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 5755.87, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6029.96, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 6029.96, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5481.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5481.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7126.31, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 5481.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5481.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5481.78, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES - SOI : 4", "code_information": [ { "code": "5144", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 28211.38, "maximum": 36674.79, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28211.38 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28634.55, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 29621.95, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31032.52, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 31032.52, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28211.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 28211.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36674.79, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 28211.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28211.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 28211.38, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Dx Bone Marrow Biopsies", "code_information": [ { "code": "38221", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6863, "discounted_cash": 2113, "minimum": 195.83, "maximum": 6176.7, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.83 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 215.41 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.83 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 205.62 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.08, "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": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 215.41 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 195.83 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 215.41 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 280.9 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 195.83 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 2536.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 254.58 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 195.83 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.83 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 195.83 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Dx Bronchoscope/Wash", "code_information": [ { "code": "31622", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12012, "discounted_cash": 2278, "minimum": 236.5756, "maximum": 10810.8, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3417.03, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 236.58 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2323.58, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "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": 260.24 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 236.58 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 248.41 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3417.03, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2300.8, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2910.9, "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": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2961.43, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 260.24 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 236.58 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 260.24 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 236.58 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2414.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 236.58 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 2733.62, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 307.55 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 236.58 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 236.58 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2910.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 236.58 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3000.95, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DYSEQUILIBRIUM", "code_information": [ { "code": "149", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7806, "minimum": 7806.05, "maximum": 14821.552, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 7806.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 10538.17, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7962.17, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7806.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 7806.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 7806.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 7806.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 7806.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 7806.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8699.77 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7884.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13942.1 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7806.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7806.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12684.83, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10147.87, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 7806.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8274.41, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7806.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 7806.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 9367.26, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7806.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7806.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7806.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12919.12 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7806.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7806.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9193.01 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 14821.55 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 13339.4 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 7806.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14373.3 } ] } ] }, { "description": "EATING DISORDERS - SOI : 1", "code_information": [ { "code": "7591", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6174.02, "maximum": 8026.23, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6174.02 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6266.63, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 6482.72, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6791.42, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 6791.42, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6174.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6174.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8026.23, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 6174.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6174.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6174.02, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEVER AND INFLAMMATORY CONDITIONS- SOI : 3", "code_information": [ { "code": "7223", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6444.35, "maximum": 8377.66, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6444.35 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6541.02, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 6766.57, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7088.79, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 7088.79, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6444.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6444.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8377.66, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 6444.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6444.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6444.35, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CCMCC", "code_information": [ { "code": "148", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8249, "minimum": 8249.89, "maximum": 15718.812, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 8249.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 11137.35, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8414.89, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8249.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 8249.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 8249.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 8249.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 8249.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8249.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 9226.43 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8332.39, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14934.31 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8249.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8249.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13406.07, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10724.86, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 8249.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8744.88, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8249.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 8249.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 9899.87, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8249.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8249.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8249.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 15434.59 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8249.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8249.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10639 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 15718.81 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 14146.93 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8249.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15396.2 } ] } ] }, { "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": 207518, "minimum": 108450, "maximum": 418560.944, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 207518, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 280149.35, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 211668.36, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 207518, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 207518, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 207518, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 207518.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 207518.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 207518, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 245681.69 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 209593.18, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 399733.8 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 207518, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 207518.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 337216.82, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 269773.45, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 207518, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 219969.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 207518, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 108450, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 58500, "10th_percentile": 58500, "90th_percentile": 58500, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 207518.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 249021.65, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 207518.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 207518.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 207518, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 369866.3 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 207518, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 207518.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 309479 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 418560.94 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 376704.85 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 207518, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 412096.7 } ] } ] }, { "description": "EAR, NOSE, MOUTH, THROAT, CRANIALFACIAL MALIGNANCIES - SOI : 2", "code_information": [ { "code": "1102", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6936.23, "maximum": 9017.1, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6936.23 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7040.27, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7283.04, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7629.85, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 7629.85, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6936.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6936.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9017.1, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 6936.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6936.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6936.23, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ELECTIVE HIP JOINT REPLACEMENT- SOI : 1", "code_information": [ { "code": "3241", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12305.64, "maximum": 15997.33, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12305.64 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12490.22, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 12920.92, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13536.2, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 13536.2, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12305.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12305.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15997.33, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 12305.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12305.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12305.64, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EATING DISORDERS - SOI : 3", "code_information": [ { "code": "7593", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13046.65, "maximum": 16960.65, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13046.65 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13242.35, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 13698.98, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14351.32, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 14351.32, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13046.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13046.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16960.65, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 13046.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13046.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13046.65, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ELECTIVE HIP JOINT REPLACEMENT- SOI : 4", "code_information": [ { "code": "3244", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 29312.83, "maximum": 38106.68, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29312.83 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29752.52, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 30778.47, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32244.11, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 32244.11, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29312.83, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 29312.83, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38106.68, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 29312.83, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29312.83, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 29312.83, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EATING DISORDERS - SOI : 4", "code_information": [ { "code": "7594", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 23951.9, "maximum": 31137.47, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23951.9 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24311.18, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 25149.5, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26347.09, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 26347.09, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23951.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 23951.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31137.47, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 23951.9, "additional_payer_notes": "100% 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" } ] } ] }, { "description": "ELECTIVE KNEE JOINT REPLACEMENT- SOI : 2", "code_information": [ { "code": "3262", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12960.78, "maximum": 16849.01, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12960.78 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13155.19, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 13608.82, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14256.86, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 14256.86, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12960.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12960.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16849.01, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 12960.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12960.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12960.78, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Egd Biopsy Single/Multiple", "code_information": [ { "code": "43239", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14942, "discounted_cash": 1160, "minimum": 335.9078, "maximum": 13447.8, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1741.22, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 335.91 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1184.03, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 369.5 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 335.91 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "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": 352.71 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 1741.22, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1172.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1483.31, "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": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1509.05, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 369.5 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 335.91 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 369.5 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 335.91 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1230.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 335.91 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 1392.97, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 436.68 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 335.91 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1483.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 335.91 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1529.19, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "ELECTIVE KNEE JOINT REPLACEMENT- SOI : 3", "code_information": [ { "code": "3263", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18607.94, "maximum": 24190.32, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18607.94 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18887.06, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 19538.34, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20468.73, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 20468.73, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18607.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18607.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24190.32, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 18607.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18607.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18607.94, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ELECTIVE HIP JOINT REPLACEMENT- SOI : 3", "code_information": [ { "code": "3243", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 19651.07, "maximum": 25546.39, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19651.07 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19945.84, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 20633.62, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21616.18, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 21616.18, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19651.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 19651.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25546.39, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 19651.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19651.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 19651.07, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ELECTIVE KNEE JOINT REPLACEMENT- SOI : 1", "code_information": [ { "code": "3261", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12205.99, "maximum": 15867.79, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12205.99 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12389.08, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 12816.29, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13426.59, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 13426.59, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12205.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12205.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15867.79, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 12205.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12205.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12205.99, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ENDOCRINE DISORDERS WITH CC", "code_information": [ { "code": "644", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10472, "minimum": 9826.22, "maximum": 20213, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 10473, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 14138.51, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10682.46, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 10473, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 10473, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 10473, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 10472.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 10472.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 10473, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 11864.38 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10577.73, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19274.58 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10473, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 10472.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 17018.58, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13614.86, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 10473, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11101.38, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10473, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 10472.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 12567.56, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10472.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10472.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10473, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 18418.46 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10473, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10472.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9826.22 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 20213 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 18191.7 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 10473, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19870.7 } ] } ] }, { "description": "ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC", "code_information": [ { "code": "267", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 46914, "minimum": 4844.28, "maximum": 93882.976, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 46914.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 63334.22, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 47852.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 46914.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 46914.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 46914.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 46914.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 46914.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 46914.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 55106.26 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 47383.34, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 87750.27 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 46914.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 46914.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 76235.64, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 60988.51, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 46914.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 49729.05, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 46914.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 46914.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 56297.09, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 46914.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 46914.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 46914.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 84662.11 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 46914.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 46914.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 4844.28 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 93882.98 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 84494.68 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 46914.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 90464.2 } ] } ] }, { "description": "ENDOCRINE DISORDERS WITHOUT CCMCC", "code_information": [ { "code": "645", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7968, "minimum": 6164.58, "maximum": 15150.876, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 7968.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 10758.1, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8128.34, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7968.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 7968.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 7968.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 7968.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 7968.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 7968.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8893.07 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8048.65, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14524 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7968.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7968.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12949.56, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10359.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 7968.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8447.1, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7968.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 11700, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 27000, "10th_percentile": 27000, "90th_percentile": 27000, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 7968.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 9562.75, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7968.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7968.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7968.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13200.16 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7968.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7968.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6164.58 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 15150.88 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 13635.79 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 7968.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14973.2 } ] } ] }, { "description": "EXC ABDL TUM DEEP < 5 CM", "code_information": [ { "code": "22900", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2019.2, "discounted_cash": 3717, "minimum": 520.465, "maximum": 2019.2, "payers_information": [ { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 579.43 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 579.43 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 753.26 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 579.43 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "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": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 579.43 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 579.43 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "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": 520.47 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 579.43 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 608.4 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "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": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 637.37 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 579.43 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 637.37 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 2019.2, "discounted_cash": 3717, "minimum": 520.465, "maximum": 2019.2, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 579.43 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "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": 520.47 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 579.43 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 608.4 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "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": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 637.37 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 579.43 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 637.37 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 579.43 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 579.43 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 753.26 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 579.43 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "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": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 579.43 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2019.2, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "FOOT & TOE PROCEDURES - SOI : 3", "code_information": [ { "code": "3143", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15322.69, "maximum": 19919.5, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15322.69 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15552.53, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 16088.82, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16854.96, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 16854.96, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15322.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15322.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19919.5, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 15322.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15322.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15322.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXC ARMELBOW LES SC < 3 CM", "code_information": [ { "code": "24075", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 20000, "discounted_cash": 2113, "minimum": 483.82, "maximum": 18000, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 532.2 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 508.01 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.08, "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": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 532.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 532.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 2536.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 628.97 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "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": 483.82 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "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": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 20000, "discounted_cash": 2113, "minimum": 483.82, "maximum": 18000, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 532.2 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 508.01 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.08, "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": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 532.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 532.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 2536.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 628.97 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "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": 483.82 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "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": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "FOOT & TOE PROCEDURES - SOI : 4", "code_information": [ { "code": "3144", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 25759.37, "maximum": 33487.18, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25759.37 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26145.76, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 27047.34, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28335.31, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 28335.31, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25759.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 25759.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33487.18, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 25759.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25759.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 25759.37, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc Back Les Sc < 3 Cm", "code_information": [ { "code": "21930", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14942, "discounted_cash": 2113, "minimum": 408.298, "maximum": 13447.8, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 532.42 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 408.3 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 532.42 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 559.04 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.08, "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": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 585.66 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 532.42 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 585.66 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 532.42 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 532.42 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 2536.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 692.15 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 532.42 }, { "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": 532.42 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 532.42 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "FOOT PROCEDURES WITH CC", "code_information": [ { "code": "504", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18707, "minimum": 18000, "maximum": 36860.624, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 18707.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 25255.54, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 19081.96, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 18707.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 18707.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 18707.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 18707.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 18707.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 18707.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 21635.99 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18894.88, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32733.62 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 18707.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 18707.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 30400.19, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 24320.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 18707.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19830.27, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 18707.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 18707.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 22449.37, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 18707.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18707.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18707.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 29961.87 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18707.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18707.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 22783.8 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 36860.62 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 33174.56 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 18707.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33746 } ] } ] }, { "description": "Exc Back Les Sc 3 Cm/>", "code_information": [ { "code": "21931", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15429.7, "discounted_cash": 2113, "minimum": 386.08, "maximum": 13886.73, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 386.08 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 424.69 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 386.08 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 405.38 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.08, "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": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 424.69 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 386.08 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 424.69 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 553.79 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 386.08 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 2536.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 501.9 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 386.08 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 386.08 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "FRACTURE OF FEMUR - SOI : 3", "code_information": [ { "code": "3403", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7442.96, "maximum": 9675.85, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7442.96 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7554.6, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7815.11, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8187.26, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 8187.26, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7442.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7442.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9675.85, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 7442.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7442.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7442.96, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc Shoulder Tum Deep 5 Cm/>", "code_information": [ { "code": "23073", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14942, "discounted_cash": 3717, "minimum": 568.5, "maximum": 13447.8, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 568.5 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 625.35 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 568.5 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 596.93 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.46, "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": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 625.35 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 568.5 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 625.35 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 815.46 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 568.5 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 4461.16, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 739.05 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 568.5 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 568.5 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "FRACTURE OF FEMUR - SOI : 4", "code_information": [ { "code": "3404", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11119.39, "maximum": 14455.21, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11119.39 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11286.18, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 11675.36, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12231.33, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 12231.33, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11119.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11119.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14455.21, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 11119.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11119.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11119.39, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc Thigh/Knee Les Sc 3 Cm/>", "code_information": [ { "code": "27337", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14942, "discounted_cash": 3717, "minimum": 345.12, "maximum": 13447.8, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 345.12 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 379.63 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 345.12 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 362.38 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.46, "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": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 379.63 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 345.12 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 379.63 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 495.04 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 345.12 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 4461.16, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 448.66 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 345.12 }, { "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": 345.12 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 345.12 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "FRACTURE OF PELVIS OR DISLOCATION OF HIP - SOI : 1", "code_information": [ { "code": "3411", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4419.56, "maximum": 5745.43, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4419.56 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4485.85, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4640.54, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4861.52, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4861.52, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5745.43, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc Thigh/Knee Tum Deep <5Cm", "code_information": [ { "code": "27328", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14942, "discounted_cash": 3717, "minimum": 554.32, "maximum": 13447.8, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 554.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 609.75 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 554.32 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 582.04 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.46, "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": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 609.75 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 554.32 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 609.75 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 554.32 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 554.32 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 4461.16, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 720.62 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 554.32 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 554.32 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 554.32 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "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": 14372, "minimum": 14372.86, "maximum": 28140.9, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 14372.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 19403.36, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 14660.36, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 14372.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 14372.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 14372.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 14372.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 14372.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 14372.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 16492.06 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 14516.63, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27296.67 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 14372.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 14372.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 23355.9, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 18684.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 14372.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15235.27, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 14372.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 14372.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 17247.43, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 14372.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14372.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14372.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 26381.23 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14372.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14372.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15576.6 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 28097.06 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 25287.35 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 14372.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28140.9 } ] } ] }, { "description": "Exc Tr-Ext B9+Marg 3.1-4 Cm", "code_information": [ { "code": "11404", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14942, "discounted_cash": 2113, "minimum": 127.1, "maximum": 13447.8, "payers_information": [ { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 2536.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 165.23 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 127.1 }, { "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": 127.1 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 127.1 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 127.1 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 139.81 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 127.1 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 133.46 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.08, "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": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 139.81 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 127.1 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 139.81 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 127.1 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 127.1 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "FRACTURES OF HIP AND PELVIS WITHOUT MCC", "code_information": [ { "code": "536", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8352, "minimum": 7628.52, "maximum": 15925.872, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 8352.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 11275.62, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8519.36, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8352.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 8352.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 8352.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 8352.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 8352.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8352.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 9347.97 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8435.83, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15124.63 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8352.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8352.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13572.5, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10858, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 8352.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8853.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8352.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 8352.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 10022.77, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8352.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8352.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8352.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13654.67 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8352.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8352.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7628.52 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 15925.87 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 14333.28 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8352.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15592.4 } ] } ] }, { "description": "EPISTAXIS WITH MCC", "code_information": [ { "code": "150", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13462, "minimum": 13462.75, "maximum": 26577.6, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 13462.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 18174.71, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13732.06, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 13462.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 13462.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 13462.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 13462.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 13462.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 13462.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 15412.11 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13597.43, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25780.27 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 13462.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 13462.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21876.97, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 17501.58, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 13462.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14270.57, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13462.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 13462.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 16155.3, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13462.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13462.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13462.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 22804.05 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13462.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13462.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18364.5 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 26257.18 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 23631.46 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 13462.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26577.6 } ] } ] }, { "description": "Excision Breast Lesion", "code_information": [ { "code": "19125", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 27230.6, "discounted_cash": 5011, "minimum": 344.9875, "maximum": 24507.54, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7516.83, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 344.99 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5111.44, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 379.49 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 344.99 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 362.24 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 7516.83, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5061.33, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6403.44, "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": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6514.59, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 379.49 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 344.99 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 379.49 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 344.99 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5311.89, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 344.99 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 6013.46, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 448.49 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 344.99 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 344.99 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6403.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 344.99 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6601.53, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "FULL TERM NEONATE WITH MAJOR PROBLEMS", "code_information": [ { "code": "793", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 41147, "minimum": 1273, "maximum": 80192.3, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 41147.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 55548.87, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 41970.25, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 41147.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 41147.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 41147.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 41147.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 41147.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 41147.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "per diem", "standard_charge_dollar": 1273 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 41558.77, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 77786.53 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 41147.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 41147.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 66864.38, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 53491.5, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 41147.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 43616.14, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 41147.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 41147.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 49376.77, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 41147.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 41147.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 41147.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 73023.28 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 41147.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 41147.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 55413 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "per diem", "standard_charge_dollar": 5579 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "per diem", "standard_charge_dollar": 5021 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 41147.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 80192.3 } ] } ] }, { "description": "EPISTAXIS WITHOUT MCC", "code_information": [ { "code": "151", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7634, "minimum": 5961.09, "maximum": 14575.2, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 7634.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 10306.4, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7787.06, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7634.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 7634.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 7634.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 7634.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 7634.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 7634.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8496.05 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7710.71, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14137.94 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7634.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7634.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12405.85, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9924.68, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 7634.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8092.43, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7634.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 7634.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 9161.24, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7634.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7634.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7634.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13370.17 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7634.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7634.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5961.09 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 14474.48 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 13027.03 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 7634.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14575.2 } ] } ] }, { "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": 35506.15, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27312.42 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27722.11, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 28678.04, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 30043.66, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 30043.66, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27312.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 27312.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35506.15, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 27312.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27312.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 27312.42, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 21757.92, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16736.86 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16987.91, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 17573.7, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18410.55, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 18410.55, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16736.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16736.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21757.92, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 16736.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16736.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16736.86, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC", "code_information": [ { "code": "392", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8079, "minimum": 7719.5, "maximum": 15373.712, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 8079.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 10906.89, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8240.76, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8079.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 8079.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 8079.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 8079.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 8079.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8079.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 9023.87 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8159.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14553.88 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8079.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8079.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13128.67, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10502.93, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 8079.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8563.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8079.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 11250, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 9000, "10th_percentile": 9000, "90th_percentile": 9000, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 8079.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 9695.02, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8079.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8079.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8079.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13628.65 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8079.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8079.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7719.5 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 15373.71 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 13836.34 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8079.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15004 } ] } ] }, { "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": 58168.11, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44744.7 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45415.87, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 46981.93, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 49219.17, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 49219.17, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44744.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 44744.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 58168.11, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 44744.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44744.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 44744.7, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT - SOI : 1", "code_information": [ { "code": "7921", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12017.29, "maximum": 15622.48, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12017.29 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12197.55, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 12618.15, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13219.02, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 13219.02, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12017.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12017.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15622.48, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 12017.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12017.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12017.29, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT - SOI : 4", "code_information": [ { "code": "7924", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 38747.72, "maximum": 50372.04, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38747.72 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39328.94, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 40685.11, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42622.49, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 42622.49, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38747.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 38747.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 50372.04, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 38747.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38747.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 38747.72, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "GASTRIC FUNDOPLICATION - SOI : 3", "code_information": [ { "code": "2323", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 17865.87, "maximum": 23225.63, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17865.87 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18133.86, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 18759.16, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19652.46, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 19652.46, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17865.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 17865.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23225.63, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 17865.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17865.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 17865.87, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc Abd Les Sc 3 Cm/>", "code_information": [ { "code": "22903", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14942, "discounted_cash": 3717, "minimum": 362.25, "maximum": 13447.8, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 362.25 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 398.48 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 362.25 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 380.36 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.46, "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": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 398.48 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 362.25 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 398.48 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 519.61 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 362.25 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 4461.16, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 470.93 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 362.25 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "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": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EXTENSIVE THIRD DEGREE BURNS WITHOUT SKIN GRAFT- SOI : 1", "code_information": [ { "code": "8431", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4519.21, "maximum": 5874.97, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4519.21 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4587, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4745.17, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4971.13, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4971.13, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4519.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4519.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5874.97, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4519.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4519.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4519.21, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "GASTROINTESTINAL OBSTRUCTION WITHOUT CCMCC", "code_information": [ { "code": "390", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 5781, "minimum": 5123.18, "maximum": 10727.68, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 5781, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 7804.35, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 5896.62, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 5781, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 5781, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 5781, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 5781, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 5781, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 5781, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 6296.8 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 5838.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10206.15 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 5781, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 5781, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 9394.13, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 7515.3, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 5781, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6127.86, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 5781, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 5781, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 6937.2, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 5781, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 5781, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 5781, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 9697.58 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 5781, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 5781, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5123.18 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 10727.68 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 9654.91 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 5781, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10521.8 } ] } ] }, { "description": "Exc h-f-nk-sp b9+marg 2.1-3", "code_information": [ { "code": "11423", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9961.34, "discounted_cash": 2113, "minimum": 124.43, "maximum": 8965.206, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 124.43 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 136.87 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 124.43 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 130.65 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.08, "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": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 136.87 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 124.43 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 136.87 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 124.43 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 124.43 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 2536.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 161.76 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 124.43 }, { "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": 124.43 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 124.43 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EXTERNAL HEART ASSIST SYSTEMS- SOI : 4", "code_information": [ { "code": "1784", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 66228.69, "maximum": 86097.3, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66228.69 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 67222.12, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 69540.12, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 72851.56, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 72851.56, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66228.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 66228.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 86097.3, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 66228.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66228.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 66228.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc H-F-Nk-Sp B9+Marg 3.1-4", "code_information": [ { "code": "11424", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14942, "discounted_cash": 2113, "minimum": 145.26, "maximum": 13447.8, "payers_information": [ { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 145.26 }, { "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": 145.26 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 145.26 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 145.26 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 159.79 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 145.26 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 152.52 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.08, "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": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 159.79 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 145.26 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 159.79 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 145.26 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 145.26 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 2536.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 188.84 } ] } ] }, { "description": "EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)- SOI : 3", "code_information": [ { "code": "0093", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 110110.47, "maximum": 143143.61, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 110110.47 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 111762.13, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 115615.99, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 121121.52, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 121121.52, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 110110.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 110110.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 143143.61, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 110110.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 110110.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 110110.47, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc Thigh/Knee Les Sc < 3 Cm", "code_information": [ { "code": "27327", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 21588, "discounted_cash": 2113, "minimum": 551.6559, "maximum": 19429.2, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 551.66 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 606.83 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 551.66 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 579.24 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.08, "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": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 606.83 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 551.66 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 606.83 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 551.66 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 551.66 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 2536.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 717.16 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 551.66 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "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": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EXTRACRANIAL PROCEDURES WITH CC", "code_information": [ { "code": "038", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16302, "minimum": 8550, "maximum": 31997.672, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 16302.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 22008.13, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 16628.35, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 16302.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 16302.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 16302.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 16302.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 16302.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 16302.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 18781.6 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16465.32, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30053.32 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 16302.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 16302.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 26491.27, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 21193.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 16302.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17280.44, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 16302.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 16302.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 19562.78, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 16302.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16302.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16302.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 27755.2 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16302.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16302.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23984.4 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 31997.67 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 28797.9 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 16302.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30982.8 } ] } ] }, { "description": "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC", "code_information": [ { "code": "391", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12846, "minimum": 12397.4, "maximum": 25010.876, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 12846.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 17342.45, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13103.23, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 12846.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 12846.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 12846.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 12846.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 12846.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 12846.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 14680.57 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12974.76, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23958.03 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 12846.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 12846.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20875.17, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16700.14, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 12846.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13617.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 12846.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 17100, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 9000, "10th_percentile": 9000, "90th_percentile": 9000, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 12846.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 15415.51, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 12846.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12846.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12846.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 22130.95 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12846.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12846.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12397.4 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 25010.88 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 22509.79 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 12846.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24699 } ] } ] }, { "description": "Exchange Nephrostomy Cath", "code_information": [ { "code": "50435", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7122, "discounted_cash": 2675, "minimum": 434.47, "maximum": 8732.97, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4013.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 434.47 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2728.92, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 477.81 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 434.47 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 456.19 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 4013.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2702.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3418.69, "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": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3478.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 477.92 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 434.47 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 477.92 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 623.06 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2835.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 434.47 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 3210.49, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 564.81 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 434.47 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 434.47 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3418.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 434.47 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3524.45, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EXTRAOCULAR PROCEDURES EXCEPT ORBIT", "code_information": [ { "code": "115", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15446, "minimum": 15446.8, "maximum": 30268.228, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 15446.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 20853.23, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 15755.74, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 15446.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 15446.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 15446.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 15446.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 15446.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 15446.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 17766.47 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15601.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28555.64 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 15446.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 15446.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 25101.12, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 20080.89, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 15446.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16373.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 15446.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 15446.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 18536.21, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15446.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15446.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15446.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 27139.34 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15446.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15446.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 27872.3 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 30268.23 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 27241.41 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 15446.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29438.8 } ] } ] }, { "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": 19528.11, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15021.62 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15246.94, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 15772.7, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16523.78, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 16523.78, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15021.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15021.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19528.11, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 15021.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15021.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15021.62, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EYE INFECTIONS AND OTHER EYE DISORDERS - SOI : 1", "code_information": [ { "code": "0821", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4419.56, "maximum": 5745.43, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4419.56 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4485.85, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4640.54, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4861.52, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4861.52, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5745.43, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 15831, "minimum": 15831.17, "maximum": 31045.196, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 15831.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 21372.08, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 16147.82, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 15831.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 15831.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 15831.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 15831.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 15831.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 15831.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 18222.52 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15989.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28081.89 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 15831.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 15831.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 25725.65, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 20580.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 15831.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16781.07, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 15831.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 15831.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 18997.4, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15831.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15831.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15831.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 28121.24 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15831.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15831.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18601.5 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 31045.2 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 27940.68 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 15831.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28950.4 } ] } ] }, { "description": "Ex Arm/Elbow Tum Deep 5 Cm/>", "code_information": [ { "code": "24073", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14942, "discounted_cash": 3717, "minimum": 572.23, "maximum": 13447.8, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 572.23 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 629.45 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 572.23 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 600.84 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.46, "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": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 629.45 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 572.23 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 629.45 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 820.81 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 572.23 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 4461.16, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 743.9 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 572.23 }, { "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": 572.23 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 572.23 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT - SOI : 4", "code_information": [ { "code": "8414", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 173017.86, "maximum": 224923.22, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 173017.86 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 175613.13, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 181668.75, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 190319.65, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 190319.65, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 173017.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 173017.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 224923.22, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 173017.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 173017.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 173017.86, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EYE INFECTIONS AND OTHER EYE DISORDERS - SOI : 2", "code_information": [ { "code": "0822", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5772.24, "maximum": 7503.91, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5772.24 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5858.82, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 6060.85, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6349.46, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 6349.46, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5772.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5772.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7503.91, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 5772.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5772.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5772.24, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "HAND PROCEDURES FOR INJURIES", "code_information": [ { "code": "906", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19635, "minimum": 14400, "maximum": 41966.1, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 19635.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 26507.88, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 20028.21, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 19635.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 19635.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 19635.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 19635.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 19635.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 19635.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 22736.77 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 19831.86, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40707.12 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 19635.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 19635.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 31907.64, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 25526.11, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 19635.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20813.63, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 19635.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 19635.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 23562.56, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 19635.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19635.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19635.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 32642.15 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19635.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19635.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 22285.9 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 38736 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 34862.4 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 19635.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 41966.1 } ] } ] }, { "description": "EXC ABD LES SC < 3 CM", "code_information": [ { "code": "22902", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3202.84, "discounted_cash": 2113, "minimum": 357.41, "maximum": 3170.73, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 357.41 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 393.15 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 357.41 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 375.28 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.08, "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": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 393.15 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 357.41 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 393.15 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 512.67 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 357.41 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 2536.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 464.63 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 357.41 }, { "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": 357.41 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 357.41 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA - SOI : 1", "code_information": [ { "code": "9111", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15548.49, "maximum": 20213.04, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15548.49 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15781.72, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 16325.91, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17103.34, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 17103.34, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15548.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15548.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20213.04, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 15548.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15548.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15548.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 27554.33, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21195.64 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21513.57, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 22255.42, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23315.2, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 23315.2, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21195.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 21195.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27554.33, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 21195.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21195.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 21195.64, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc Arm/Elbow Les Sc 3 Cm/>", "code_information": [ { "code": "24071", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14942, "discounted_cash": 3717, "minimum": 334.7, "maximum": 13447.8, "payers_information": [ { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 334.7 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 368.17 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 334.7 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 351.44 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.46, "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": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 368.17 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 334.7 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 368.17 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 480.09 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 334.7 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 4461.16, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 435.11 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 334.7 }, { "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": 334.7 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 334.7 } ] } ] }, { "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": 24538.98, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18876.14 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19159.28, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 19819.95, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20763.75, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 20763.75, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18876.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18876.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24538.98, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 18876.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18876.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18876.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM MALIGNANCY - SOI : 1", "code_information": [ { "code": "5301", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4830.88, "maximum": 6280.14, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4830.88 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4903.34, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 5072.42, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5313.97, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 5313.97, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4830.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4830.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6280.14, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4830.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4830.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4830.88, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Hc Intrapulmonary Surfactant Administj Phys/Qhp", "code_information": [ { "code": "94610", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 551.88, "discounted_cash": 280, "minimum": 165.564, "maximum": 496.692, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 420.39, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 285.87, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 420.39, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 283.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "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": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 364.34, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "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 CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 297.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 336.31, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "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": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 369.2, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Exc Back Tum Deep < 5 Cm", "code_information": [ { "code": "21932", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 17532.3, "discounted_cash": 3717, "minimum": 554.35, "maximum": 15779.07, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 554.35 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 609.79 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 554.35 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 582.07 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.46, "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": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 609.79 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 554.35 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 609.79 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 795.16 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 554.35 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 4461.16, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 720.66 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 554.35 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 554.35 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 554.35 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS- SOI : 3", "code_information": [ { "code": "9503", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 26055.14, "maximum": 33871.68, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26055.14 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26445.97, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 27357.9, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28660.65, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 28660.65, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26055.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 26055.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33871.68, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 26055.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26055.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 26055.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM MALIGNANCY - SOI : 2", "code_information": [ { "code": "5302", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6392.4, "maximum": 8310.12, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6392.4 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6488.29, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6392.4, "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": 6712.02, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7031.64, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 7031.64, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6392.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6392.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8310.12, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 6392.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6392.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6392.4, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Hc R&L Hrt Cath Chd Img Cath Trgt Zone Nml Nt Connj", "code_information": [ { "code": "93596", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14807.6, "discounted_cash": 4149, "minimum": 383.394, "maximum": 13326.84, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6223.85, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4232.21, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "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": 383.39 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6223.85, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4190.72, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5301.97, "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": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5394, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4398.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 4979.08, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5302.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5465.99, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EXC FACE LES SBQ 2 CM<", "code_information": [ { "code": "21012", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13333.34, "discounted_cash": 2113, "minimum": 281.09, "maximum": 12000.006, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 281.09 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 309.2 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 281.09 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 295.14 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.08, "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": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 309.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 281.09 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 309.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 403.2 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 281.09 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 2536.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 365.42 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 281.09 }, { "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": 281.09 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 281.09 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 13333.3, "discounted_cash": 2113, "minimum": 281.09, "maximum": 12000.006, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 281.09 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 309.2 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 281.09 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 295.14 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.08, "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": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 309.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 281.09 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 309.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 403.2 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 281.09 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 2536.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 365.42 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 281.09 }, { "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": 281.09 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 281.09 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC", "code_information": [ { "code": "982", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 24456, "minimum": 18450, "maximum": 48481.62, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 24456.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 33015.87, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 24945.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 24456.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 24456.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 24456.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 24456.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 24456.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 24456.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 28457.14 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 24700.76, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 45664.69 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 24456.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 24456.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 39741.33, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 31793.06, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 24456.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25923.57, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 24456.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 24456.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 29347.44, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 24456.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 24456.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 24456.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 43127.33 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 24456.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 24456.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 28452.8 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 48481.62 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 43633.46 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 24456.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 47077 } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES - SOI : 2", "code_information": [ { "code": "5142", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11619.76, "maximum": 15105.69, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11619.76 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11794.06, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 12200.75, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12781.74, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 12781.74, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11619.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11619.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15105.69, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 11619.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11619.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11619.76, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXC HIP PELVIS LES SC 3 CM>", "code_information": [ { "code": "27043", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1867.75, "discounted_cash": 3717, "minimum": 385.7, "maximum": 1867.75, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1867.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1867.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 385.7 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1867.75, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1867.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1867.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 1867.75, "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": 424.27 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 385.7 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1867.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1867.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1867.75, "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": 404.99 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1867.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 1867.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1867.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1867.75, "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": 1867.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 1867.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1867.75, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 424.27 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 385.7 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 424.27 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 1867.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 553.25 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1867.75, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 385.7 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1867.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 1867.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 1867.75, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1867.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 501.41 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 385.7 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1867.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 385.7 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1867.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1867.75, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1867.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 385.7 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1867.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1867.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1867.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1867.75, "additional_payer_notes": "131.74% 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": 46241, "minimum": 39150, "maximum": 92522.296, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 46241.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 62425.58, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 47166.02, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 46241.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 46241.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 46241.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 46241.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 46241.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 46241.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 54307.59 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 46703.61, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 88667.89 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 46241.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 46241.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 75141.9, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 60113.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 46241.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 49015.67, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 46241.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 46241.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 55489.4, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 46241.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 46241.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 46241.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 82236.85 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 46241.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 46241.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 67006 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 92522.3 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 83270.07 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 46241.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 91410.2 } ] } ] }, { "description": "Exc Neck Tum Deep 5 Cm/>", "code_information": [ { "code": "21554", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14942, "discounted_cash": 3717, "minimum": 605.36, "maximum": 13447.8, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 605.36 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 665.9 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 605.36 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 635.63 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.46, "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": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 665.9 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 605.36 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 665.9 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 868.33 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 605.36 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 4461.16, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 786.97 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 605.36 }, { "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": 605.36 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 605.36 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT - SOI : 3", "code_information": [ { "code": "7923", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 22449.74, "maximum": 29184.66, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22449.74 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22786.49, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 23572.23, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24694.71, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 24694.71, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22449.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 22449.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29184.66, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 22449.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22449.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 22449.74, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEVER AND INFLAMMATORY CONDITIONS- SOI : 1", "code_information": [ { "code": "7221", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3387.02, "maximum": 4403.13, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3387.02 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3437.83, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 3556.37, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3725.72, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 3725.72, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3387.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3387.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4403.13, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 3387.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3387.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3387.02, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc Shoulder Les Sc 3 Cm/>", "code_information": [ { "code": "23071", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14942, "discounted_cash": 2113, "minimum": 344.38, "maximum": 13447.8, "payers_information": [ { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 344.38 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 344.38 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 378.82 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 344.38 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 361.6 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.08, "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": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 378.82 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 344.38 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 378.82 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 493.98 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 344.38 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 2536.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 447.69 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 344.38 }, { "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": 344.38 } ] } ] }, { "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": 7723.04, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5940.8 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6029.91, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 6237.84, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6534.88, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 6534.88, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5940.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5940.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7723.04, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 5940.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5940.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5940.8, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc Tr-Ext B9+Marg >4.0 Cm", "code_information": [ { "code": "11406", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14942, "discounted_cash": 2113, "minimum": 277.15, "maximum": 13447.8, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 277.15 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 304.87 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 277.15 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 291.01 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.08, "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": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 304.87 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 277.15 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 304.87 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 277.15 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 277.15 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 2536.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 360.3 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 277.15 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "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": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EXTERNAL HEART ASSIST SYSTEMS- SOI : 3", "code_information": [ { "code": "1783", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 53704.67, "maximum": 69816.07, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 53704.67 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54510.24, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 56389.9, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 59075.14, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 59075.14, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 53704.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 53704.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 69816.07, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 53704.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 53704.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 53704.67, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exploration Of Chest", "code_information": [ { "code": "32100", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 21588, "minimum": 725.749, "maximum": 19429.2, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 725.75 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 798.33 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 725.75 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 762.04 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 798.33 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 725.75 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 798.33 }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 725.75 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 725.75 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 943.48 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 725.75 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 725.75 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 725.75 } ] } ] }, { "description": "EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)- SOI : 1", "code_information": [ { "code": "0091", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 48887.57, "maximum": 63553.84, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48887.57 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 49620.88, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 51331.95, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 53776.33, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 53776.33, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48887.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 48887.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 63553.84, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 48887.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48887.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 48887.57, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT - SOI : 3", "code_information": [ { "code": "8413", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 52320.18, "maximum": 68016.23, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 52320.18 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 53104.98, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 54936.19, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 57552.2, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 57552.2, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 52320.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 52320.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 68016.23, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 52320.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 52320.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 52320.18, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)- SOI : 4", "code_information": [ { "code": "0094", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 194638.6, "maximum": 253030.18, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 194638.6 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 197558.18, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 204370.53, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 214102.46, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 214102.46, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 194638.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 194638.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 253030.18, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 194638.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 194638.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 194638.6, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA - SOI : 4", "code_information": [ { "code": "9114", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 54718.12, "maximum": 71133.56, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54718.12 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55538.89, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 57454.03, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 60189.93, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 60189.93, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54718.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 54718.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 71133.56, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 54718.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54718.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 54718.12, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE", "code_information": [ { "code": "790", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 58451, "minimum": 1273, "maximum": 114309.4, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 58451, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 78908.86, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 59620.02, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 58451, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 58451, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 58451, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 58451.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 58451.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 58451, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "per diem", "standard_charge_dollar": 1273 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 59035.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 110880.12 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 58451, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 58451.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 94982.89, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 75986.31, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 58451, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 61958.06, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 58451, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 58451.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 70141.21, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 58451.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 58451.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 58451, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 104090.22 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 58451, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 58451.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8792.01 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "per diem", "standard_charge_dollar": 6276 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "per diem", "standard_charge_dollar": 5650 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 58451, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 114309.4 } ] } ] }, { "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": 38460, "minimum": 11700, "maximum": 83199.6, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 38460.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 51922.2, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 39230.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 38460.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 38460.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 38460.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 38460.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 38460.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 38460.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 45075.37 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 38845.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 80703.61 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 38460.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 38460.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 62498.95, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 49999.16, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 38460.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 40768.55, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 38460.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 38460.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 46153.07, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 38460.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 38460.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 38460.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 52599.38 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 38460.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 38460.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 57491 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 76793.62 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 69114.26 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 38460.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 83199.6 } ] } ] }, { "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": 14532.38, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11178.75 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11346.43, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 11737.69, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12296.63, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 12296.63, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11178.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11178.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14532.38, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 11178.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11178.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11178.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FOOT & TOE PROCEDURES - SOI : 1", "code_information": [ { "code": "3141", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8097.04, "maximum": 10526.15, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8097.04 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8218.5, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 8501.89, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8906.74, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 8906.74, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8097.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8097.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10526.15, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 8097.04, "additional_payer_notes": "100% 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" } ] } ] }, { "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": 16140.66, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12415.89 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12602.13, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 13036.68, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13657.48, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 13657.48, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12415.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12415.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16140.66, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 12415.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12415.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12415.89, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM INFECTIONS - SOI : 3", "code_information": [ { "code": "5313", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8474.44, "maximum": 11016.77, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8474.44 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8601.56, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 8898.16, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9321.88, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 9321.88, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8474.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8474.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11016.77, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 8474.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8474.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8474.44, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 9209, "minimum": 8803.98, "maximum": 17659.26, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 9209.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 12433.15, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9393.93, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9209.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 9209.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 9209.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 9209.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 9209.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 9209.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 10365.41 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9301.84, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16670.81 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9209.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9209.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14965.83, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11972.66, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 9209.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9762.32, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9209.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 9209.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 11051.69, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9209.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9209.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9209.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 15536.94 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9209.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9209.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8803.98 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 17659.26 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 15893.33 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 9209.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17186.4 } ] } ] }, { "description": "EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CCMCC", "code_information": [ { "code": "983", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17193, "minimum": 9000, "maximum": 33800.08, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 17193.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 23211.75, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 17537.78, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 17193.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 17193.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 17193.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 17193.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 17193.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 17193.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 19839.55 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 17365.84, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31114.59 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 17193.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 17193.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 27940.07, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 22352.06, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 17193.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18225.53, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 17193.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 17193.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 20632.67, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 17193.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17193.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17193.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 28367.58 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 17193.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17193.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15202 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 33800.08 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 30420.07 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 17193.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32076.9 } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM INFECTIONS - SOI : 4", "code_information": [ { "code": "5314", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15745.67, "maximum": 20469.37, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15745.67 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15981.86, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 16532.95, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17320.24, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 17320.24, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15745.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15745.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20469.37, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 15745.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15745.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15745.67, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK - SOI : 1", "code_information": [ { "code": "3421", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4320.97, "maximum": 5617.26, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4320.97 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4385.78, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4537.02, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4753.07, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4753.07, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4320.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4320.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5617.26, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4320.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4320.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4320.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 19901.57, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15308.9 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15538.53, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 16074.35, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16839.79, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 16839.79, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15308.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15308.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19901.57, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 15308.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15308.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15308.9, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES - SOI : 3", "code_information": [ { "code": "5143", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15285.58, "maximum": 19871.25, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15285.58 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15514.86, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 16049.86, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16814.14, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 16814.14, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15285.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15285.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19871.25, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 15285.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15285.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15285.58, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK - SOI : 2", "code_information": [ { "code": "3422", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5791.33, "maximum": 7528.73, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5791.33 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5878.2, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 6080.9, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6370.46, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 6370.46, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5791.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5791.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7528.73, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 5791.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5791.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5791.33, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTERNAL HEART ASSIST SYSTEMS- SOI : 2", "code_information": [ { "code": "1782", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 43293.42, "maximum": 56281.45, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 43293.42 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 43942.82, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 45458.09, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 47622.76, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 47622.76, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 43293.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 43293.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 56281.45, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 43293.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 43293.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 43293.42, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEVER AND INFLAMMATORY CONDITIONS", "code_information": [ { "code": "864", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9133, "minimum": 7560.29, "maximum": 17505.444, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 9133.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 12330.44, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9316.33, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9133.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 9133.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 9133.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 9133.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 9133.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 9133.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 10275.13 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9225, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16749.18 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9133.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9133.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14842.2, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11873.76, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 9133.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9681.68, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9133.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 9133.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 10960.39, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9133.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9133.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9133.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 15314.89 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9133.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9133.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7560.29 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 17505.44 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 15754.9 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 9133.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17267.2 } ] } ] }, { "description": "FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK - SOI : 4", "code_information": [ { "code": "3424", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15077.8, "maximum": 19601.14, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15077.8 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15303.97, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 15831.69, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16585.58, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 16585.58, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15077.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15077.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19601.14, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 15077.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15077.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15077.8, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)- SOI : 2", "code_information": [ { "code": "0092", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 60423.58, "maximum": 78550.65, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 60423.58 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 61329.93, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 63444.76, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66465.94, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 66465.94, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 60423.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 60423.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 78550.65, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 60423.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 60423.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 60423.58, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEVER AND INFLAMMATORY CONDITIONS- SOI : 4", "code_information": [ { "code": "7224", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8918.62, "maximum": 11594.21, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8918.62 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9052.4, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 9364.55, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9810.48, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 9810.48, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8918.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8918.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11594.21, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 8918.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8918.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8918.62, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Fragmenting Of Kidney Stone", "code_information": [ { "code": "50590", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 17868, "discounted_cash": 4511, "minimum": 961.2488, "maximum": 16081.2, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6767.24, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 961.25 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4601.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 1057.38 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 961.25 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 1009.31 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6767.24, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4556.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5764.87, "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": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1057.38 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 961.25 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 1057.38 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 961.25 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4782.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 961.25 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 5413.79, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1249.63 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 961.25 }, { "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": 961.25 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5764.91, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 961.25 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5943.21, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc (Sup Shell A4315) Cath W/Drainage 2-Way Silcne", "code_information": [ { "code": "A4315", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Commercial (03-01-2023 to 12-31-2026)", "methodology": "percent of total billed charges", "standard_charge_percentage": 55, "median_amount": 20.38, "10th_percentile": 20.38, "90th_percentile": 86.16, "count": "1 through 10" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "percent of total billed charges", "standard_charge_percentage": 30, "median_amount": 1685.61, "10th_percentile": 1685.61, "90th_percentile": 1685.61, "count": "1 through 10" } ] } ] }, { "description": "EXTRACRANIAL PROCEDURES WITH MCC", "code_information": [ { "code": "037", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 32587, "minimum": 22050, "maximum": 64920.212, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 32587.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 43993.31, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 33239.35, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 32587.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 32587.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 32587.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 32587.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 32587.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 32587.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 38106.06 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 32913.48, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 61940.13 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 32587.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 32587.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 52954.92, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 42363.93, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 32587.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 34542.86, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 32587.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 32587.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 39105.17, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 32587.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 32587.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 32587.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 58560.18 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 32587.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 32587.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 54548.8 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 64920.21 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 58428.19 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 32587.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 63855.8 } ] } ] }, { "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": 50937.07, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39182.36 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39770.1, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 41141.48, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 43100.6, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 43100.6, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39182.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 39182.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 50937.07, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 39182.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39182.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 39182.36, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES", "code_information": [ { "code": "748", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14007, "minimum": 6300, "maximum": 27357.556, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 14007.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 18909.53, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 14287.24, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 14007.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 14007.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 14007.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 14007.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 14007.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 14007.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 16058 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 14147.17, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25409.05 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 14007.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 14007.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 22761.47, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 18209.18, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 14007.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14847.53, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 14007.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 14007.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 16808.47, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 14007.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14007.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14007.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 24372.32 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14007.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14007.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23081.9 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 27357.56 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 24621.8 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 14007.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26194.9 } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES - SOI : 1", "code_information": [ { "code": "5141", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7944.39, "maximum": 10327.71, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7944.39 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8063.56, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 8341.61, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8738.83, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 8738.83, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7944.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7944.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10327.71, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 7944.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7944.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7944.39, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "GASTROINTESTINAL HEMORRHAGE WITH MCC", "code_information": [ { "code": "377", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18305, "minimum": 18305.9, "maximum": 36048.16, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 18305.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 24712.99, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 18672.02, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 18305.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 18305.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 18305.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 18305.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 18305.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 18305.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 21159.1 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18488.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33912.36 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 18305.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 18305.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 29747.12, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 23797.7, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 18305.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19404.25, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 18305.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 18305.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 21967.1, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 18305.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18305.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18305.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 31058.27 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18305.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18305.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20278.5 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 36048.16 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 32443.34 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 18305.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34961.2 } ] } ] }, { "description": "FEVER AND INFLAMMATORY CONDITIONS- SOI : 2", "code_information": [ { "code": "7222", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4749.25, "maximum": 6174.03, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4749.25 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4820.49, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4986.71, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5224.18, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 5224.18, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4749.25, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4749.25, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6174.03, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4749.25, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4749.25, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4749.25, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FOOT & TOE PROCEDURES - SOI : 2", "code_information": [ { "code": "3142", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10597.82, "maximum": 13777.17, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10597.82 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10756.79, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 11127.71, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11657.6, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 11657.6, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10597.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10597.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13777.17, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 10597.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10597.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10597.82, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "GASTROINTESTINAL HEMORRHAGE WITHOUT CCMCC", "code_information": [ { "code": "379", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6623, "minimum": 6623.8, "maximum": 12431.488, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 6623.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 8942.13, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6756.28, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6623.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 6623.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 6623.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 6623.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 6623.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 6623.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 7296.88 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6690.04, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11875.52 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6623.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6623.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 10763.68, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 8610.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 6623.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7021.23, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6623.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 6623.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 7948.56, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6623.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6623.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6623.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 10984.81 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6623.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6623.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8167.17 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 12431.49 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 11188.34 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 6623.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12242.8 } ] } ] }, { "description": "Fixation Of Knee Joint", "code_information": [ { "code": "27570", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4052, "discounted_cash": 2058, "minimum": 111.61, "maximum": 3646.8, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3087.02, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 111.61 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2099.17, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 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": "Altamed", "plan_name": "Altamed Pace Duals", "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": 122.77 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 111.61 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 117.19 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3087.02, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2078.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2629.77, "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": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 122.77 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 111.61 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 122.77 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 111.61 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2181.49, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 111.61 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 2469.61, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 145.09 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 111.61 }, { "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": 111.61 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2629.78, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 111.61 }, { "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": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2711.12, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "FRACTURE OF FEMUR - SOI : 1", "code_information": [ { "code": "3401", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4081.39, "maximum": 5305.81, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4081.39 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4142.61, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 4285.46, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4489.53, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 4489.53, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4081.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4081.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5305.81, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 4081.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4081.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4081.39, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "GASTROINTESTINAL VASCULAR INSUFFICIENCY - SOI : 2", "code_information": [ { "code": "2462", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6330.92, "maximum": 8230.2, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6330.92 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6425.88, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 6647.47, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6964.01, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 6964.01, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6330.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6330.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8230.2, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 6330.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6330.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6330.92, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURE OF FEMUR - SOI : 2", "code_information": [ { "code": "3402", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5213.57, "maximum": 6777.64, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5213.57 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5291.77, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 5474.25, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5734.93, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 5734.93, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5213.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5213.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6777.64, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 5213.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5213.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5213.57, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FOOT PROCEDURES WITH MCC", "code_information": [ { "code": "503", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 27700, "minimum": 27700.58, "maximum": 55040.492, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 27700.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 37395.78, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 28254.61, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 27700.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 27700.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 27700.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 27700.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 27700.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 27700.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 32306.98 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 27977.61, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 49363.4 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 27700.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 27700.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 45013.44, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 36010.75, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 27700.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 29362.64, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 27700.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 27700.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 33240.7, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 27700.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 27700.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 27700.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 46525.82 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 27700.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 27700.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 35164.4 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 55040.49 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 49536.44 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 27700.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 50890.1 } ] } ] }, { "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": 7134.58, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5488.14 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5570.46, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 5762.55, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6036.95, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 6036.95, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5488.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5488.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7134.58, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 5488.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5488.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5488.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FOOT PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "505", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17962, "minimum": 17162.7, "maximum": 35354.016, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 17962.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 24249.44, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 18321.75, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 17962.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 17962.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 17962.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 17962.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 17962.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 17962.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 20751.66 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18142.13, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32733.62 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 17962.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 17962.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 29189.14, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 23351.32, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 17962.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19040.25, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 17962.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 17962.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 21555.06, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 17962.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17962.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17962.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 29590.62 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 17962.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17962.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17162.7 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 35354.02 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 31818.61 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 17962.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33746 } ] } ] }, { "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": 10447.61, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8036.62 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8157.17, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 8438.45, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8840.28, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 8840.28, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8036.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8036.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10447.61, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 8036.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8036.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8036.62, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURE OF PELVIS OR DISLOCATION OF HIP - SOI : 4", "code_information": [ { "code": "3414", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14089.79, "maximum": 18316.73, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14089.79 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14301.14, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 14794.28, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15498.77, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 15498.77, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14089.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14089.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18316.73, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 14089.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14089.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14089.79, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURES OF FEMUR WITH MCC", "code_information": [ { "code": "533", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15766, "minimum": 15766.79, "maximum": 30915.044, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 15766.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 21285.17, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 16082.14, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 15766.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 15766.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 15766.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 15766.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 15766.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 15766.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 18146.13 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15924.47, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28441.86 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 15766.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 15766.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 25621.03, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 20496.83, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 15766.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16712.81, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 15766.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 15766.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 18920.15, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15766.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15766.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15766.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 28301.66 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15766.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15766.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20260.5 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 30915.04 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 27823.54 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 15766.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29321.5 } ] } ] }, { "description": "FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK - SOI : 3", "code_information": [ { "code": "3423", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8404.47, "maximum": 10925.81, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8404.47 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8530.54, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 8824.69, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9244.92, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 9244.92, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8404.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8404.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10925.81, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 8404.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8404.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8404.47, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURES OF HIP AND PELVIS WITH MCC", "code_information": [ { "code": "535", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12979, "minimum": 12979.9, "maximum": 25571.9, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 12979.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 17522.87, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13239.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 12979.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 12979.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 12979.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 12979.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 12979.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 12979.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 14839.15 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13109.7, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24804.74 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 12979.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 12979.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21092.34, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16873.87, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 12979.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13758.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 12979.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 12979.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 15575.88, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 12979.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12979.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12979.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 22495.26 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12979.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12979.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17670.2 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 25281.04 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 22752.94 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 12979.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25571.9 } ] } ] }, { "description": "FRACTURES OF FEMUR WITHOUT MCC", "code_information": [ { "code": "534", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8337, "minimum": 6214.85, "maximum": 15896.292, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 8337.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 11255.87, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8504.43, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8337.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 8337.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 8337.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 8337.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 8337.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8337.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 9330.61 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8421.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15182.44 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8337.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8337.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13548.73, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10838.98, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 8337.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8837.94, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8337.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 8337.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 10005.22, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8337.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8337.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8337.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 14051.95 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8337.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8337.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6214.85 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 15896.29 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 14306.66 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8337.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15652 } ] } ] }, { "description": "Frenulotomy Of Penis", "code_information": [ { "code": "54164", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 20192, "discounted_cash": 2675, "minimum": 155.25, "maximum": 18172.8, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4013.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 155.25 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2728.92, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 170.78 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 155.25 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 163.01 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 4013.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2702.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3418.69, "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": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3478.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 170.78 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 155.25 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 170.78 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 222.69 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2835.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 155.25 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 3210.49, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 201.83 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 155.25 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 155.25 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3418.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 155.25 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3524.45, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY", "code_information": [ { "code": "934", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 22038, "minimum": 4357.1, "maximum": 43593.032, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 22038, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 29751.34, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 22478.76, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 22038, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 22038, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 22038, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 22038.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 22038.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 22038, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 25587.7 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 22258.38, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40022.59 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 22038, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 22038.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 35811.8, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 28649.44, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 22038, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 23360.28, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 22038, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 22038.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 26445.64, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 22038.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 22038.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 22038, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 36300.86 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 22038, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 22038.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 4357.1 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 43593.03 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 39233.73 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 22038, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 41260.4 } ] } ] }, { "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": 70441, "minimum": 41181.8, "maximum": 141445.644, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 70441.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 95095.86, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 71850.23, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 70441.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 70441.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 70441.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 70441.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 70441.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 70441.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 83024 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 71145.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 124572.25 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 70441.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 70441.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 114467.24, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 91573.79, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 70441.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 74667.88, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 70441.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 70441.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 84529.66, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 70441.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 70441.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 70441.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 120043.52 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 70441.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 70441.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 41181.8 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 141445.64 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 127301.08 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 70441.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 128425 } ] } ] }, { "description": "Hc Radiation Treatment Management 5 Treatments", "code_information": [ { "code": "77427", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 844, "minimum": 164.05, "maximum": 759.6, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 164.05 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 180.46 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 164.05 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 172.25 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 180.46 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 164.05 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 180.46 }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 164.05 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 164.05 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 213.27 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 164.05 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 164.05 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 164.05 } ] } ] }, { "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": 31892, "minimum": 20855.4, "maximum": 63514.176, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 31892.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 43054.39, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 32529.94, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 31892.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 31892.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 31892.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 31892.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 31892.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 31892.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 37280.76 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 32211.02, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 59319.57 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 31892.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 31892.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 51824.73, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 41459.78, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 31892.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 33805.63, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 31892.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 31892.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 38270.57, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 31892.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 31892.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 31892.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 55782.76 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 31892.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 31892.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20855.4 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 63514.18 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 57162.76 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 31892.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 61154.2 } ] } ] }, { "description": "Hc Rem Interrog Pm/Ldls Pm <90 D Phys/Qhp", "code_information": [ { "code": "93294", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 372, "minimum": 31.34, "maximum": 334.8, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 31.34 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 34.47 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 31.34 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 32.91 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 34.47 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 31.34 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 34.47 }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.95 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 31.34 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 40.74 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 31.34 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 31.34 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 31.34 } ] } ] }, { "description": "GASTRIC FUNDOPLICATION - SOI : 2", "code_information": [ { "code": "2322", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11514.81, "maximum": 14969.25, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11514.81 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11687.53, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 12090.55, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12666.29, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 12666.29, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11514.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11514.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14969.25, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 11514.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11514.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11514.81, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "GASTRIC FUNDOPLICATION - SOI : 1", "code_information": [ { "code": "2321", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9808.05, "maximum": 12750.47, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9808.05 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9955.17, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 10298.45, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10788.85, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 10788.85, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9808.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9808.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12750.47, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 9808.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9808.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9808.05, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Hc Rpr Lac 2.5 Cm/< Pst One-Third Tongue", "code_information": [ { "code": "41251", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1058, "discounted_cash": 303, "minimum": 110, "maximum": 952.2, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 303.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 454.7, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 110 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 309.19, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 303.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 303.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 303.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 110 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 303.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 303.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 303.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 115.5 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 303.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 454.7, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 306.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 387.35, "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": 303.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 303.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 394.07, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 110 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 121 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 303.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 110 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 321.32, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 110 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 303.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 303.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 363.76, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 303.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 143 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 110 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 303.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 110 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 303.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 387.35, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 303.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 110 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 303.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 303.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 303.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 399.33, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "GASTRIC FUNDOPLICATION - SOI : 4", "code_information": [ { "code": "2324", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 27793.7, "maximum": 36131.81, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27793.7 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28210.61, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 29183.39, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 30573.07, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 30573.07, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27793.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 27793.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36131.81, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 27793.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27793.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 27793.7, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "GASTROINTESTINAL OBSTRUCTION WITH CC", "code_information": [ { "code": "389", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8178, "minimum": 6912.71, "maximum": 15574.856, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 8178.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 11041.22, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8342.25, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8178.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 8178.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 8178.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 8178.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 8178.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8178.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 9141.94 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8260.47, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14951.1 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8178.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8178.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13290.36, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10632.28, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 8178.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8669.4, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8178.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 8178.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 9814.42, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8178.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8178.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8178.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13816.01 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8178.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8178.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6912.71 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 15574.86 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 14017.37 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8178.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15413.5 } ] } ] }, { "description": "GASTROINTESTINAL HEMORRHAGE WITH CC", "code_information": [ { "code": "378", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10040, "minimum": 10040.8, "maximum": 19339.404, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 10040.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 13555.13, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10241.62, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 10040.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 10040.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 10040.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 10040.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 10040.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 10040.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 11351.6 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10141.21, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18388.58 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10040.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 10040.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16316.37, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13053.09, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 10040.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10643.25, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10040.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 13050, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 31500, "10th_percentile": 31500, "90th_percentile": 31500, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 10040.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 12049.01, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10040.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10040.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10040.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 17067.04 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10040.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10040.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10469 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 19339.4 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 17405.46 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 10040.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18957.3 } ] } ] }, { "description": "GASTROINTESTINAL OBSTRUCTION WITH MCC", "code_information": [ { "code": "388", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14880, "minimum": 14880.1, "maximum": 29122.496, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 14880.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 20088.14, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 15177.7, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 14880.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 14880.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 14880.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 14880.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 14880.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 14880.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 17093.96 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15028.9, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27415.98 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 14880.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 14880.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 24180.16, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 19344.13, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 14880.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15772.91, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 14880.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 14880.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 17856.12, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 14880.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14880.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14880.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 25215.44 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14880.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14880.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14978.1 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 29122.5 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 26210.25 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 14880.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28263.9 } ] } ] }, { "description": "GASTROINTESTINAL VASCULAR INSUFFICIENCY - SOI : 1", "code_information": [ { "code": "2461", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5157.39, "maximum": 6704.61, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5157.39 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5234.75, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 5415.26, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5673.13, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 5673.13, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5157.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5157.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6704.61, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 5157.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5157.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5157.39, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "GASTROINTESTINAL VASCULAR INSUFFICIENCY - SOI : 4", "code_information": [ { "code": "2464", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13256.55, "maximum": 17233.51, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13256.55 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13455.4, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 13919.38, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14582.2, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 14582.2, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13256.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13256.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17233.51, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 13256.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13256.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13256.55, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "GASTROINTESTINAL VASCULAR INSUFFICIENCY - SOI : 3", "code_information": [ { "code": "2463", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9026.75, "maximum": 11734.77, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9026.75 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9162.15, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 9478.09, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9929.43, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 9929.43, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9026.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9026.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11734.77, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 9026.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9026.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9026.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "HAND & WRIST PROCEDURES - SOI : 3", "code_information": [ { "code": "3163", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14722.67, "maximum": 19139.47, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14722.67 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14943.51, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 15458.8, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16194.94, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 16194.94, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14722.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14722.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19139.47, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 14722.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14722.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14722.67, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "HAND & WRIST PROCEDURES - SOI : 4", "code_information": [ { "code": "3164", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 24919.77, "maximum": 32395.7, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24919.77 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25293.57, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 26165.76, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27411.75, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 27411.75, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24919.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 24919.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32395.7, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 24919.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24919.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 24919.77, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "HAND & WRIST PROCEDURES - SOI : 1", "code_information": [ { "code": "3161", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7086.77, "maximum": 9212.8, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7086.77 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7193.07, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 7441.11, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7795.45, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 7795.45, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7086.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7086.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9212.8, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 7086.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7086.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7086.77, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "514", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10446, "minimum": 10446.6, "maximum": 20159.756, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "case rate", "standard_charge_dollar": 10446.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "case rate", "standard_charge_dollar": 14102.95, "additional_payer_notes": "135.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10655.53, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 10446.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "case rate", "standard_charge_dollar": 10446.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "case rate", "standard_charge_dollar": 10446.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 10446.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "case rate", "standard_charge_dollar": 10446.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 10446.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 11833.12 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10551.07, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19017.14 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10446.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "case rate", "standard_charge_dollar": 10446.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16975.77, "additional_payer_notes": "162.50% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13580.62, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "case rate", "standard_charge_dollar": 10446.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11073.4, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10446.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "case rate", "standard_charge_dollar": 10446.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "case rate", "standard_charge_dollar": 12535.96, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10446.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10446.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10446.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 18068.03 }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10446.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10446.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11657.6 }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 20159.76 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 18143.78 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 10446.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19605.3 } ] } ] }, { "description": "HAND & WRIST PROCEDURES - SOI : 2", "code_information": [ { "code": "3162", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9594.97, "maximum": 12473.46, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9594.97 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9738.89, "additional_payer_notes": "101.5% of State Medicaid Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC 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": 10074.72, "additional_payer_notes": "105% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10554.47, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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 LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "case rate", "standard_charge_dollar": 10554.47, "additional_payer_notes": "110% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12473.46, "additional_payer_notes": "130% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "case rate", "standard_charge_dollar": 9594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9594.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Hc Vnpnxr 3 Years/> Phys/Qhp Skill", "code_information": [ { "code": "36410", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 675, "minimum": 15.49, "maximum": 607.5, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.49 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.04 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.49 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.26 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.04 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 15.49 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 17.04 }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.49 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 15.49 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.14 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 15.49 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.49 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 15.49 } ] } ] }, { "description": "Hc Iaad Ia Hepatitis B Surface Ag Neutralization", "code_information": [ { "code": "87341", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 112, "discounted_cash": 10, "minimum": 7.34, "maximum": 100.8, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.5, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.54, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 10.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 10.33, "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": 10.1 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 10.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 10.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.71 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 15.5, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.43, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.2, "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": 10.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 10.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.43, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.07 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 8.07 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 10.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.17 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.95, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 10.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 12.4, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 10.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.54 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.2, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 17.56 }, { "payer_name": "UHC", "plan_name": "UHC Commercial Select Navigate Core (08-14-2020 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 17.56 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.61, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Placement Needle Pelvic Organ Radioelement Appl", "code_information": [ { "code": "55920", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 21357.7, "discounted_cash": 6402, "minimum": 344.01, "maximum": 19221.93, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9603.68, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 344.01 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6530.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 378.41 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 344.01 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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 Cal Mediconnect", "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": 361.21 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 9603.68, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6466.47, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8181.18, "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": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8323.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 378.41 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 344.01 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 378.41 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 493.45 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6786.6, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 344.01 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 7682.94, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 447.21 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 344.01 }, { "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": 344.01 }, { "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": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8181.24, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "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": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8434.27, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Therapeutic Radiology Tx Planning Complex", "code_information": [ { "code": "77263", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1377.5, "minimum": 124.14, "maximum": 1239.75, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 124.14 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 331.51 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 124.14 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.35 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 136.55 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 124.14 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 136.55 }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 206.9 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 124.14 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 161.38 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 124.14 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 124.14 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 124.14 } ] } ] }, { "description": "Hc (Sup Shell A4215) Sterile Needle", "code_information": [ { "code": "A4215", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "standard_charge_algorithm": "Not To Exceed $3500", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 0.45, "10th_percentile": 0.45, "90th_percentile": 0.45, "count": "1 through 10" } ] } ] }, { "description": "Hc (Sup Shell A4223) Infusion Supplies W/O Pump", "code_information": [ { "code": "A4223", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Commercial (03-01-2023 to 12-31-2026)", "methodology": "percent of total billed charges", "standard_charge_percentage": 55, "median_amount": 6.19, "10th_percentile": 6.19, "90th_percentile": 11.47, "count": "1 through 10" } ] } ] }, { "description": "Hc (Sup Shell A4657) Syringe W/Wo Needle", "code_information": [ { "code": "A4657", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "standard_charge_algorithm": "Not To Exceed $3500", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 0.45, "10th_percentile": 0.45, "90th_percentile": 0.45, "count": "1 through 10" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "percent of total billed charges", "standard_charge_percentage": 30, "median_amount": 400.5, "10th_percentile": 363.75, "90th_percentile": 15721.31, "count": "1 through 10" } ] } ] }, { "description": "Hc (Sup Shell A5200) Percutaneous Catheter Anchor", "code_information": [ { "code": "A5200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Commercial (03-01-2023 to 12-31-2026)", "methodology": "percent of total billed charges", "standard_charge_percentage": 55, "median_amount": 7.51, "10th_percentile": 7.51, "90th_percentile": 7.51, "count": "1 through 10" } ] } ] }, { "description": "Hc (Sup Shell A6402) Sterile Gauze <= 16 Sq In - A6402 - 27200152", "code_information": [ { "code": "A6402", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Commercial (03-01-2023 to 12-31-2026)", "methodology": "percent of total billed charges", "standard_charge_percentage": 55, "median_amount": 6.6, "10th_percentile": 3.3, "90th_percentile": 16.5, "count": "1 through 10" } ] } ] }, { "description": "Hc (Sup Shell A6402) Sterile Gauze <= 16 Sq In - A6402 - RU272059", "code_information": [ { "code": "A6402", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Commercial (03-01-2023 to 12-31-2026)", "methodology": "percent of total billed charges", "standard_charge_percentage": 55, "median_amount": 6.6, "10th_percentile": 3.3, "90th_percentile": 16.5, "count": "1 through 10" } ] } ] }, { "description": "Hc (Sup Shell C1771) Rep Dev, Urinary, W/Sling", "code_information": [ { "code": "C1771", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "UHC", "plan_name": "UHC Commercial All Payer (08-14-2020 to 12-31-2026)", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.48, "median_amount": 5110.75, "10th_percentile": 5110.75, "90th_percentile": 5110.75, "count": "1 through 10" } ] } ] }, { "description": "Hc 1St Hosp/Birthing Center Care Per Day Nml Nb - 99460 - 76199460", "code_information": [ { "code": "99460", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 347.79, "discounted_cash": 170, "minimum": 47.2, "maximum": 313.011, "payers_information": [ { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "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": 51.92 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 47.2 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "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": 49.56 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 255.59, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 172.09, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.73, "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": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 221.51, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 51.92 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 47.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 51.92 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 67.7 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 180.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 47.2 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 204.47, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 61.36 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 47.2 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 47.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.73, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 47.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 255.59, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 47.2 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 173.8, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "Hc 1St Hosp/Birthing Center Care Per Day Nml Nb - Z7500 - 76199460", "code_information": [ { "code": "Z7500", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 347.79, "minimum": 34.0957, "maximum": 1049.949, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 34.1 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 37.51 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 34.1 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 35.81 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 37.51 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 34.1 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 37.51 }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 34.1 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 34.1 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.33 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 34.1 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 34.1 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 34.1 } ] } ] }, { "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": 1150.65, "discounted_cash": 305, "minimum": 129.18, "maximum": 1887.624, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 458.07, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 129.18 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 311.49, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "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": 236.83 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 129.18 }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Cal Mediconnect", "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": 135.64 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 458.07, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 308.43, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Coventry Healthcare WC, INC.", "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": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 396.99, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 142.1 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 129.18 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal LA All Care Medical Group AppleCare Medical Group OmniCare", "methodology": "fee schedule", "standard_charge_dollar": 142.1 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare Applecare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 215.3 }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 323.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 129.18 }, { "payer_name": "Kaiser Hospital Foundation", "plan_name": "Kaiser Hospital Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Cal Medi-Connect", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA", "methodology": "fee schedule", "standard_charge_dollar": 366.46, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 167.93 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medi-Cal - IPA", "methodology": "fee schedule", "standard_charge_dollar": 129.18 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 129.18 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 390.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "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": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 402.29, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "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": 1150.65, "discounted_cash": 1003, "minimum": 345.195, "maximum": 1150.65, "payers_information": [ { "payer_name": "Welbe Health PACE", "plan_name": "Welbe Health PACE Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Aetna Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1150.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1023.38, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Altamed", "plan_name": "Altamed Pace Duals", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Avanti Hospitals, LLC", "plan_name": "Avanti Hospitals, LLC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name