{ "hospital_name": "Hollywood Presbyterian Medical Center", "last_updated_on": "2025-11-19", "version": "2.0.0", "hospital_location": [ "Hollywood Presbyterian Medical Center" ], "hospital_address": [ "1300 N Vermont Ave, Los Angeles, CA 90027, Los Angeles, CA 90027" ], "license_information": { "state": "CA" }, "affirmation": { "affirmation": "To the best of its knowledge and belief, the 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 indicated.", "confirm_affirmation": true }, "standard_charge_information": [ { "description": "Intensive Care Unit - Burn Care", "code_information": [ { "code": "0207", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 2250, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 4053, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 4053, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 4053, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 4053, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 4509, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 4509, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 4509, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 4509, "methodology": "per diem" }, { "payer_name": "AltaMed", "plan_name": "Medi-Cal", "standard_charge_dollar": 2400, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 4344, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 4344, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 4344, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 4344, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 5077.85, "methodology": "per diem" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Medi-Cal", "standard_charge_dollar": 1705, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Senior", "standard_charge_dollar": 4788.41, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Covered California (Qualified Health Plan)", "standard_charge_dollar": 2850, "methodology": "per diem" } ], "minimum": 1705, "maximum": 5077.85 } ] }, { "description": "Room & Board - Private (One Bed) - Obstetrics (OB)", "code_information": [ { "code": "0112", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 300, "methodology": "per diem" }, { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 2459, "methodology": "per diem" }, { "payer_name": "AltaMed", "plan_name": "Medi-Cal", "standard_charge_dollar": 2250, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3473.73, "methodology": "per diem" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Medi-Cal", "standard_charge_dollar": 1512.5, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "HMO Salud Con Benefit Program", "standard_charge_dollar": 10640, "methodology": "case rate" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 2180.97, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 2180.97, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 2180.97, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 2180.97, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 2180.97, "methodology": "percent of total billed charges" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 2665, "methodology": "per diem" } ], "minimum": 300, "maximum": 10640 } ] }, { "description": "Room & Board - Semi-private (Two Beds) - Obstetrics (OB)", "code_information": [ { "code": "0122", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 300, "methodology": "per diem" }, { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 2459, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3473.73, "methodology": "per diem" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Medi-Cal", "standard_charge_dollar": 1512.5, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "HMO Salud Con Benefit Program", "standard_charge_dollar": 10640, "methodology": "case rate" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 1955.25, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 1955.25, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 1955.25, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 1955.25, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 1955.25, "methodology": "percent of total billed charges" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 2665, "methodology": "per diem" } ], "minimum": 300, "maximum": 10640 } ] }, { "description": "Room & Board - Three and Four Beds - Obstetrics (OB)", "code_information": [ { "code": "0132", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 300, "methodology": "per diem" }, { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 2459, "methodology": "per diem" }, { "payer_name": "AltaMed", "plan_name": "Medi-Cal", "standard_charge_dollar": 2250, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3473.73, "methodology": "per diem" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Medi-Cal", "standard_charge_dollar": 1512.5, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "HMO Salud Con Benefit Program", "standard_charge_dollar": 10640, "methodology": "case rate" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 2665, "methodology": "per diem" } ], "minimum": 300, "maximum": 10640 } ] }, { "description": "Room & Board - Ward - Obstetrics (OB)", "code_information": [ { "code": "0152", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 300, "methodology": "per diem" }, { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 2459, "methodology": "per diem" }, { "payer_name": "AltaMed", "plan_name": "Medi-Cal", "standard_charge_dollar": 2250, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3473.73, "methodology": "per diem" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Medi-Cal", "standard_charge_dollar": 1512.5, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "HMO Salud Con Benefit Program", "standard_charge_dollar": 10640, "methodology": "case rate" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 2665, "methodology": "per diem" } ], "minimum": 300, "maximum": 10640 } ] }, { "description": "Nursery - Newborn - Level I", "code_information": [ { "code": "0171", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 300, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 742, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 742, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 742, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 742, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 616, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 616, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 616, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 616, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 826, "methodology": "per diem" }, { "payer_name": "AltaMed", "plan_name": "Medi-Cal", "standard_charge_dollar": 662, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 759, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 759, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 759, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 759, "methodology": "case rate" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 857.93, "methodology": "per diem" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Medi-Cal", "standard_charge_dollar": 1512.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Senior", "standard_charge_dollar": 1233.21, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Covered California (Qualified Health Plan)", "standard_charge_dollar": 735, "methodology": "per diem" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 720.23, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 720.23, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 720.23, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 720.23, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 720.23, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 889, "methodology": "per diem" } ], "minimum": 300, "maximum": 1512.5 } ] }, { "description": "Labor Room/Delivery - Birthing center", "code_information": [ { "code": "0724", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 2200, "methodology": "case rate" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3677.7, "methodology": "per diem" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Medi-Cal", "standard_charge_dollar": 4357.5, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 315, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 315, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 315, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 315, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 315, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 358, "methodology": "fee schedule" } ], "minimum": 315, "maximum": 4357.5 } ] }, { "description": "Room & Board - Other - Other", "code_information": [ { "code": "0169", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 250, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 2459, "methodology": "per diem" }, { "payer_name": "AltaMed", "plan_name": "Medi-Cal", "standard_charge_dollar": 2250, "methodology": "per diem" }, { "payer_name": "SelectCare", "plan_name": "Commercial", "standard_charge_percentage": 43, "estimated_amount": 327.79, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3268.73, "methodology": "per diem" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Medi-Cal", "standard_charge_dollar": 1512.5, "methodology": "per diem" }, { "payer_name": "LA Care", "plan_name": "PASC-SEIU", "standard_charge_dollar": 900, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Senior", "standard_charge_dollar": 3080.5, "methodology": "per diem" }, { "payer_name": "LA Care", "plan_name": "Medi-Cal", "standard_charge_dollar": 900, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Covered California (Qualified Health Plan)", "standard_charge_dollar": 1839, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "HMO Salud Con Benefit Program", "standard_charge_dollar": 10640, "methodology": "case rate" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 343.04, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 343.04, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 343.04, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 343.04, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 343.04, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 2665, "methodology": "per diem" } ], "minimum": 250, "maximum": 10640 } ] }, { "description": "Subacute Care - General Classification", "code_information": [ { "code": "0190", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 1402.33, "methodology": "fee schedule" }, { "payer_name": "Prospect Health Plan", "plan_name": "Medi-Cal", "standard_charge_dollar": 960, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 1354, "methodology": "per diem" }, { "payer_name": "AltaMed", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 1402.33, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare Advantage", "standard_charge_dollar": 675, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 1242, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 1242, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 1242, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 1242, "methodology": "case rate" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 1224.88, "methodology": "per diem" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 1402.33, "methodology": "fee schedule" }, { "payer_name": "Pipeline formerly Avanti", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 1402.33, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 1038, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 1038, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 1038, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 1038, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 1038, "methodology": "per diem" }, { "payer_name": "Alta Hospital Systems", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 1402.33, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1038, "methodology": "per diem" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 1402.33, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "Medi-Cal", "standard_charge_dollar": 900, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Covered California (Qualified Health Plan)", "standard_charge_dollar": 689, "methodology": "per diem" }, { "payer_name": "Valley Presbyterian Medical Center", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 1402.33, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medi-Cal", "standard_charge_percentage": 104, "estimated_amount": 1458.42, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 1402.33, "methodology": "fee schedule" }, { "payer_name": "Kaiser", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 1402.33, "methodology": "fee schedule" }, { "payer_name": "Anthem", "plan_name": "Medi-Cal Managed Care", "standard_charge_percentage": 100, "estimated_amount": 1402.33, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 1402.33, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN Network", "standard_charge_dollar": 583, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 1402.33, "methodology": "fee schedule" }, { "payer_name": "Kern Health Systems", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 1402.33, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 1270, "methodology": "per diem" }, { "payer_name": "Blue Shield of California", "plan_name": "Commercial", "standard_charge_dollar": 1271, "methodology": "per diem" } ], "minimum": 583, "maximum": 1458.42 } ] }, { "description": "Subacute Care - Other", "code_information": [ { "code": "0199", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 1242.39, "methodology": "fee schedule" }, { "payer_name": "Prospect Health Plan", "plan_name": "Medi-Cal", "standard_charge_dollar": 960, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 1354, "methodology": "per diem" }, { "payer_name": "SCAN", "plan_name": "Medicare Advantage", "standard_charge_dollar": 675, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 1242, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 1242, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 1242, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 1242, "methodology": "case rate" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 1224.88, "methodology": "per diem" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 1242.39, "methodology": "fee schedule" }, { "payer_name": "Pipeline formerly Avanti", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 1242.39, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 1038, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 1038, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 1038, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 1038, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 1038, "methodology": "per diem" }, { "payer_name": "Alta Hospital Systems", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 1242.39, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1038, "methodology": "per diem" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 1242.39, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "Medi-Cal", "standard_charge_dollar": 900, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Covered California (Qualified Health Plan)", "standard_charge_dollar": 689, "methodology": "per diem" }, { "payer_name": "Valley Presbyterian Medical Center", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 1242.39, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medi-Cal", "standard_charge_percentage": 104, "estimated_amount": 1292.09, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 1242.39, "methodology": "fee schedule" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 343.04, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 343.04, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 343.04, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 343.04, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 343.04, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 1242.39, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN Network", "standard_charge_dollar": 583, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 1242.39, "methodology": "fee schedule" }, { "payer_name": "Kern Health Systems", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 1242.39, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 1270, "methodology": "per diem" }, { "payer_name": "Blue Shield of California", "plan_name": "Commercial", "standard_charge_dollar": 1271, "methodology": "per diem" } ], "minimum": 343.04, "maximum": 1354 } ] }, { "description": "Subacute Care - Level I", "code_information": [ { "code": "0191", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 250, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 981, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 981, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 981, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 981, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 1354, "methodology": "per diem" }, { "payer_name": "SCAN", "plan_name": "Medicare Advantage", "standard_charge_dollar": 225, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 1242, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 1242, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 1242, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 1242, "methodology": "case rate" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 1224.88, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 1038, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 1038, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 1038, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 1038, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 1038, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1038, "methodology": "per diem" }, { "payer_name": "LA Care", "plan_name": "Medi-Cal", "standard_charge_dollar": 900, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Covered California (Qualified Health Plan)", "standard_charge_dollar": 689, "methodology": "per diem" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN Network", "standard_charge_dollar": 583, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 1270, "methodology": "per diem" }, { "payer_name": "Blue Shield of California", "plan_name": "Commercial", "standard_charge_dollar": 543, "methodology": "per diem" } ], "minimum": 225, "maximum": 1354 } ] }, { "description": "Room & Board - Three and Four Beds - Hospice", "code_information": [ { "code": "0135", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 975, "methodology": "per diem" }, { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 11813, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Medi-Cal", "standard_charge_dollar": 1512.5, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 2853, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 2853, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 2853, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 2853, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 2853, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 2853, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "HMO Salud Con Benefit Program", "standard_charge_dollar": 10640, "methodology": "case rate" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 12595, "methodology": "case rate" } ], "minimum": 975, "maximum": 12595 } ] }, { "description": "Labor Room/Delivery - General Classification", "code_information": [ { "code": "0720", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 1400, "methodology": "case rate" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3473.73, "methodology": "per diem" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Medi-Cal", "standard_charge_dollar": 3025, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 315, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 315, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 315, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 315, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 315, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 358, "methodology": "fee schedule" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 383.13, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 383.13, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 383.13, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 383.13, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 383.13, "methodology": "percent of total billed charges" } ], "minimum": 315, "maximum": 3473.73 } ] }, { "description": "Leave of Absence - General Classification", "code_information": [ { "code": "0180", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 1400, "methodology": "case rate" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3473.73, "methodology": "per diem" } ], "minimum": 1400, "maximum": 3473.73 } ] }, { "description": "Leave of Absence - Patient Convenience", "code_information": [ { "code": "0182", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 1400, "methodology": "case rate" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3473.73, "methodology": "per diem" } ], "minimum": 1400, "maximum": 3473.73 } ] }, { "description": "Leave of Absence - Therapeutic Leave", "code_information": [ { "code": "0183", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 1400, "methodology": "case rate" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3473.73, "methodology": "per diem" } ], "minimum": 1400, "maximum": 3473.73 } ] }, { "description": "Leave of Absence - Nursing Home (for Hospitalization)", "code_information": [ { "code": "0185", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 1400, "methodology": "case rate" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3473.73, "methodology": "per diem" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 625.19, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 625.19, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 625.19, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 625.19, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 625.19, "methodology": "percent of total billed charges" } ], "minimum": 625.19, "maximum": 3473.73 } ] }, { "description": "Vaginal Delivery with O.R. Procedures Except Sterilization and/or D&C", "code_information": [ { "code": "768", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 1400, "methodology": "case rate" }, { "payer_name": "Alta Hospital Systems", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 10210.18, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "HMO", "standard_charge_percentage": 120, "estimated_amount": 12252.22, "methodology": "fee schedule" }, { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 4630, "methodology": "case rate" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 5053, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 10210.18, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 10210.18, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 5102, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 5102, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 5102, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 5102, "methodology": "case rate" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3473.73, "methodology": "per diem" }, { "payer_name": "LA Care", "plan_name": "DSNP", "standard_charge_percentage": 100, "estimated_amount": 10210.18, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Self-Funded EPO/PPO", "standard_charge_percentage": 120, "estimated_amount": 12252.22, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 2606, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 2606, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 2606, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 2606, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 2606, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 2729, "methodology": "per diem" }, { "payer_name": "New Century Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 10210.18, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Enhanced PPO", "standard_charge_dollar": 8952, "methodology": "case rate" }, { "payer_name": "LA Care", "plan_name": "L.A. Care Covered California", "standard_charge_percentage": 114.99999999999999, "estimated_amount": 11741.71, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Senior HMO", "standard_charge_percentage": 100, "estimated_amount": 10210.18, "methodology": "fee schedule" }, { "payer_name": "Alignment", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 10210.18, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 10210.18, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Duals", "standard_charge_percentage": 100, "estimated_amount": 10210.18, "methodology": "fee schedule" }, { "payer_name": "Pipeline formerly Avanti", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 10210.18, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 10210.18, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 10210.18, "methodology": "fee schedule" }, { "payer_name": "Imperial Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 10210.18, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 10210.18, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "C-SNP (Chronic Special Needs Plan)", "standard_charge_percentage": 100, "estimated_amount": 10210.18, "methodology": "fee schedule" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 4630, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN Network", "standard_charge_dollar": 6772, "methodology": "case rate" }, { "payer_name": "LA Care", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 10210.18, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Special Needs Plan (SNP)", "standard_charge_percentage": 100, "estimated_amount": 10210.18, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Medicare Advantage Prescription Drug (MAPD)", "standard_charge_percentage": 100, "estimated_amount": 10210.18, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 5388, "methodology": "case rate" }, { "payer_name": "Brand New Day", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 10210.18, "methodology": "fee schedule" }, { "payer_name": "Access Senior Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 10210.18, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 10210.18, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Commercial", "standard_charge_dollar": 7782, "methodology": "case rate" }, { "payer_name": "AltaMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 10210.18, "methodology": "fee schedule" }, { "payer_name": "Clever Care Health", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "estimated_amount": 10210.18, "methodology": "fee schedule" }, { "payer_name": "Anthem", "plan_name": "Medicare Advantage", "standard_charge_percentage": 106, "estimated_amount": 10822.79, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 10210.18, "methodology": "fee schedule" }, { "payer_name": "California State Prison", "plan_name": "Prison Healthcare Provider Network Project", "standard_charge_percentage": 125, "estimated_amount": 12762.73, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 10210.18, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Commercial", "standard_charge_percentage": 130, "estimated_amount": 13273.23, "methodology": "fee schedule" }, { "payer_name": "Medicare", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 10210.18, "methodology": "fee schedule" }, { "payer_name": "K-Day", "plan_name": "PACE", "standard_charge_percentage": 100, "estimated_amount": 10210.18, "methodology": "fee schedule" } ], "minimum": 1400, "maximum": 13273.23 } ] }, { "description": "Cesarean Section with Sterilization with MCC", "code_information": [ { "code": "783", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 1400, "methodology": "case rate" }, { "payer_name": "Alta Hospital Systems", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 15191.69, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "HMO", "standard_charge_percentage": 120, "estimated_amount": 18230.03, "methodology": "fee schedule" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 6743, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 15191.69, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 15191.69, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 6481, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 6481, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 6481, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 6481, "methodology": "case rate" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3473.73, "methodology": "per diem" }, { "payer_name": "LA Care", "plan_name": "DSNP", "standard_charge_percentage": 100, "estimated_amount": 15191.69, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Self-Funded EPO/PPO", "standard_charge_percentage": 120, "estimated_amount": 18230.03, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 2606, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 2606, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 2606, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 2606, 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"807", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 1400, "methodology": "case rate" }, { "payer_name": "Alta Hospital Systems", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 5484.38, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "HMO", "standard_charge_percentage": 120, "estimated_amount": 6581.26, "methodology": "fee schedule" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 2749, "methodology": "per diem" }, { "payer_name": 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3473.73, "methodology": "per diem" }, { "payer_name": "LA Care", "plan_name": "DSNP", "standard_charge_percentage": 100, "estimated_amount": 5484.38, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Self-Funded EPO/PPO", "standard_charge_percentage": 120, "estimated_amount": 6581.26, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 2606, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 2606, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 2606, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 2606, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 2606, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 2729, "methodology": "per diem" }, { "payer_name": "New Century Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 5484.38, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Enhanced PPO", "standard_charge_dollar": 8952, "methodology": "case rate" }, { "payer_name": "LA Care", "plan_name": "L.A. Care Covered California", "standard_charge_percentage": 114.99999999999999, "estimated_amount": 6307.04, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Senior HMO", "standard_charge_percentage": 100, "estimated_amount": 5484.38, "methodology": "fee schedule" }, { "payer_name": "Alignment", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 5484.38, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 5484.38, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Duals", "standard_charge_percentage": 100, "estimated_amount": 5484.38, "methodology": "fee schedule" }, { "payer_name": "Pipeline formerly Avanti", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 5484.38, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 5484.38, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 5484.38, "methodology": "fee schedule" }, { "payer_name": "Imperial Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 5484.38, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 5484.38, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "C-SNP (Chronic Special Needs Plan)", "standard_charge_percentage": 100, "estimated_amount": 5484.38, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN Network", "standard_charge_dollar": 6772, "methodology": "case rate" }, { "payer_name": "LA Care", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 5484.38, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Special Needs Plan (SNP)", "standard_charge_percentage": 100, "estimated_amount": 5484.38, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Medicare Advantage Prescription Drug (MAPD)", "standard_charge_percentage": 100, "estimated_amount": 5484.38, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 5388, "methodology": "case rate" }, { "payer_name": "Brand New Day", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 5484.38, "methodology": "fee schedule" }, { "payer_name": "Access Senior Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 5484.38, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 5484.38, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Commercial", "standard_charge_dollar": 7782, "methodology": "case rate" }, { "payer_name": "AltaMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 5484.38, "methodology": "fee schedule" }, { "payer_name": "Clever Care Health", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "estimated_amount": 5484.38, "methodology": "fee schedule" }, { "payer_name": "Anthem", "plan_name": "Medicare Advantage", "standard_charge_percentage": 106, "estimated_amount": 5813.44, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 5484.38, "methodology": "fee schedule" }, { "payer_name": "California State Prison", "plan_name": "Prison Healthcare Provider Network Project", "standard_charge_percentage": 125, "estimated_amount": 6855.48, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 5484.38, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Commercial", "standard_charge_percentage": 130, "estimated_amount": 7129.69, "methodology": "fee schedule" }, { "payer_name": "Medicare", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 5484.38, "methodology": "fee schedule" }, { "payer_name": "K-Day", "plan_name": "PACE", "standard_charge_percentage": 100, "estimated_amount": 5484.38, "methodology": "fee schedule" } ], "minimum": 1400, "maximum": 8952 } ] }, { "description": "All Inclusive Rate - Room and Board Plus Ancillary", "code_information": [ { "code": "0100", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 850, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 2459, "methodology": "per diem" }, { "payer_name": "AltaMed", "plan_name": "Medi-Cal", "standard_charge_dollar": 2250, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3268.73, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Senior", "standard_charge_dollar": 3080.5, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 3011, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 3011, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 3011, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 3011, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 3011, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Covered California (Qualified Health Plan)", "standard_charge_dollar": 1839, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "HMO Salud Con Benefit Program", "standard_charge_dollar": 10640, "methodology": "case rate" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 2665, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 3154, "methodology": "per diem" } ], "minimum": 850, "maximum": 10640 } ] }, { "description": "All Inclusive Rate - Room and Board", "code_information": [ { "code": "0101", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 850, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 2459, "methodology": "per diem" }, { "payer_name": "AltaMed", "plan_name": "Medi-Cal", "standard_charge_dollar": 2250, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3268.73, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Senior", "standard_charge_dollar": 3080.5, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 3011, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 3011, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 3011, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 3011, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 3011, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Covered California (Qualified Health Plan)", "standard_charge_dollar": 1839, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "HMO Salud Con Benefit Program", "standard_charge_dollar": 10640, "methodology": "case rate" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 2665, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 3154, "methodology": "per diem" } ], "minimum": 850, "maximum": 10640 } ] }, { "description": "Room & Board - Private (One Bed) - General Classification", "code_information": [ { "code": "0110", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 850, "methodology": "per diem" }, { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 2459, "methodology": "per diem" }, { "payer_name": "AltaMed", "plan_name": "Medi-Cal", "standard_charge_dollar": 2250, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3268.73, "methodology": "per diem" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Medi-Cal", "standard_charge_dollar": 1512.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Senior", "standard_charge_dollar": 3080.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Covered California (Qualified Health Plan)", "standard_charge_dollar": 1839, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "HMO Salud Con Benefit Program", "standard_charge_dollar": 10640, "methodology": "case rate" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 2665, "methodology": "per diem" } ], "minimum": 850, "maximum": 10640 } ] }, { "description": "Room & Board - Private (One Bed) - Medical/Surgical/GYN", "code_information": [ { "code": "0111", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 850, "methodology": "per diem" }, { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 2459, "methodology": "per diem" }, { "payer_name": "AltaMed", "plan_name": "Medi-Cal", "standard_charge_dollar": 2250, "methodology": "per diem" }, { "payer_name": "SelectCare", "plan_name": "Commercial", "standard_charge_percentage": 43, "estimated_amount": 2075.71, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3268.73, "methodology": "per diem" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Medi-Cal", "standard_charge_dollar": 1512.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Senior", "standard_charge_dollar": 3080.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Covered California (Qualified Health Plan)", "standard_charge_dollar": 1839, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "HMO Salud Con Benefit Program", "standard_charge_dollar": 10640, "methodology": "case rate" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 2172.26, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 2172.26, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 2172.26, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 2172.26, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 2172.26, "methodology": "percent of total billed charges" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 2665, "methodology": "per diem" } ], "minimum": 850, "maximum": 10640 } ] }, { "description": "Room & Board - Private (One Bed) - Other", "code_information": [ { "code": "0119", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 850, "methodology": "per diem" }, { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 2459, "methodology": "per diem" }, { "payer_name": "AltaMed", "plan_name": "Medi-Cal", "standard_charge_dollar": 2250, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3268.73, "methodology": "per diem" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Medi-Cal", "standard_charge_dollar": 1512.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Senior", "standard_charge_dollar": 3080.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Covered California (Qualified Health Plan)", "standard_charge_dollar": 1839, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "HMO Salud Con Benefit Program", "standard_charge_dollar": 10640, "methodology": "case rate" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 2665, "methodology": "per diem" } ], "minimum": 850, "maximum": 10640 } ] }, { "description": "Room & Board - Semi-private (Two Beds) - General Classification", "code_information": [ { "code": "0120", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 850, "methodology": "per diem" }, { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 2459, "methodology": "per diem" }, { "payer_name": "AltaMed", "plan_name": "Medi-Cal", "standard_charge_dollar": 2250, "methodology": "per diem" }, { "payer_name": "SelectCare", "plan_name": "Commercial", "standard_charge_percentage": 43, "estimated_amount": 1849.43, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3268.73, "methodology": "per diem" }, { "payer_name": "Humana", "plan_name": "Medicare Network PFFS", "standard_charge_dollar": 1850, "methodology": "per diem" }, { "payer_name": "Humana", "plan_name": "Medicare HMO", "standard_charge_dollar": 1850, "methodology": "per diem" }, { "payer_name": "Humana", "plan_name": "Medicare POS", "standard_charge_dollar": 1850, "methodology": "per diem" }, { "payer_name": "Humana", "plan_name": "Medicare PPO", "standard_charge_dollar": 1850, "methodology": "per diem" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Medi-Cal", "standard_charge_dollar": 1512.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Senior", "standard_charge_dollar": 3080.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Covered California (Qualified Health Plan)", "standard_charge_dollar": 1839, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "HMO Salud Con Benefit Program", "standard_charge_dollar": 10640, "methodology": "case rate" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 1935.45, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 1935.45, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 1935.45, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 1935.45, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 1935.45, "methodology": "percent of total billed charges" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 2665, "methodology": "per diem" } ], "minimum": 850, "maximum": 10640 } ] }, { "description": "Room & Board - Semi-private (Two Beds) - Medical/Surgical/GYN", "code_information": [ { "code": "0121", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 850, "methodology": "per diem" }, { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 2459, "methodology": "per diem" }, { "payer_name": "AltaMed", "plan_name": "Medi-Cal", "standard_charge_dollar": 2250, "methodology": "per diem" }, { "payer_name": "SelectCare", "plan_name": "Commercial", "standard_charge_percentage": 43, "estimated_amount": 1849.43, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3268.73, "methodology": "per diem" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Medi-Cal", "standard_charge_dollar": 1512.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Senior", "standard_charge_dollar": 3080.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Covered California (Qualified Health Plan)", "standard_charge_dollar": 1839, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "HMO Salud Con Benefit Program", "standard_charge_dollar": 10640, "methodology": "case rate" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 1935.45, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 1935.45, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 1935.45, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 1935.45, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 1935.45, "methodology": "percent of total billed charges" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 2665, "methodology": "per diem" } ], "minimum": 850, "maximum": 10640 } ] }, { "description": "Room & Board - Semi-private (Two Beds) - Other", "code_information": [ { "code": "0129", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 850, "methodology": "per diem" }, { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 2459, "methodology": "per diem" }, { "payer_name": "AltaMed", "plan_name": "Medi-Cal", "standard_charge_dollar": 2250, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3268.73, "methodology": "per diem" }, { "payer_name": "Humana", "plan_name": "Medicare Network PFFS", "standard_charge_dollar": 1850, "methodology": "per diem" }, { "payer_name": "Humana", "plan_name": "Medicare HMO", "standard_charge_dollar": 1850, "methodology": "per diem" }, { "payer_name": "Humana", "plan_name": "Medicare POS", "standard_charge_dollar": 1850, "methodology": "per diem" }, { "payer_name": "Humana", "plan_name": "Medicare PPO", "standard_charge_dollar": 1850, "methodology": "per diem" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Medi-Cal", "standard_charge_dollar": 1512.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Senior", "standard_charge_dollar": 3080.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Covered California (Qualified Health Plan)", "standard_charge_dollar": 1839, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "HMO Salud Con Benefit Program", "standard_charge_dollar": 10640, "methodology": "case rate" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 2665, "methodology": "per diem" } ], "minimum": 850, "maximum": 10640 } ] }, { "description": "Room & Board - Three and Four Beds - General Classification", "code_information": [ { "code": "0130", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 850, "methodology": "per diem" }, { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 2459, "methodology": "per diem" }, { "payer_name": "AltaMed", "plan_name": "Medi-Cal", "standard_charge_dollar": 2250, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3268.73, "methodology": "per diem" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Medi-Cal", "standard_charge_dollar": 1512.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Senior", "standard_charge_dollar": 3080.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Covered California (Qualified Health Plan)", "standard_charge_dollar": 1839, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "HMO Salud Con Benefit Program", "standard_charge_dollar": 10640, "methodology": "case rate" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 2665, "methodology": "per diem" } ], "minimum": 850, "maximum": 10640 } ] }, { "description": "Room & Board - Three and Four Beds - Medical/Surgical/GYN", "code_information": [ { "code": "0131", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 850, "methodology": "per diem" }, { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 2459, "methodology": "per diem" }, { "payer_name": "AltaMed", "plan_name": "Medi-Cal", "standard_charge_dollar": 2250, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3268.73, "methodology": "per diem" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Medi-Cal", "standard_charge_dollar": 1512.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Senior", "standard_charge_dollar": 3080.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Covered California (Qualified Health Plan)", "standard_charge_dollar": 1839, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "HMO Salud Con Benefit Program", "standard_charge_dollar": 10640, "methodology": "case rate" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 2665, "methodology": "per diem" } ], "minimum": 850, "maximum": 10640 } ] }, { "description": "Room & Board - Three and Four Beds - Other", "code_information": [ { "code": "0139", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 850, "methodology": "per diem" }, { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 2459, "methodology": "per diem" }, { "payer_name": "AltaMed", "plan_name": "Medi-Cal", "standard_charge_dollar": 2250, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3268.73, "methodology": "per diem" }, { "payer_name": "Humana", "plan_name": "Medicare Network PFFS", "standard_charge_dollar": 1850, "methodology": "per diem" }, { "payer_name": "Humana", "plan_name": "Medicare HMO", "standard_charge_dollar": 1850, "methodology": "per diem" }, { "payer_name": "Humana", "plan_name": "Medicare POS", "standard_charge_dollar": 1850, "methodology": "per diem" }, { "payer_name": "Humana", "plan_name": "Medicare PPO", "standard_charge_dollar": 1850, "methodology": "per diem" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Medi-Cal", "standard_charge_dollar": 1512.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Senior", "standard_charge_dollar": 3080.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Covered California (Qualified Health Plan)", "standard_charge_dollar": 1839, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "HMO Salud Con Benefit Program", "standard_charge_dollar": 10640, "methodology": "case rate" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 2665, "methodology": "per diem" } ], "minimum": 850, "maximum": 10640 } ] }, { "description": "Room & Board - Deluxe Private - General Classification", "code_information": [ { "code": "0140", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 850, "methodology": "per diem" }, { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 2459, "methodology": "per diem" }, { "payer_name": "AltaMed", "plan_name": "Medi-Cal", "standard_charge_dollar": 2250, "methodology": "per diem" }, { "payer_name": "SelectCare", "plan_name": "Commercial", "standard_charge_percentage": 43, "estimated_amount": 2667.72, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3268.73, "methodology": "per diem" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Medi-Cal", "standard_charge_dollar": 1512.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Senior", "standard_charge_dollar": 3080.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Covered California (Qualified Health Plan)", "standard_charge_dollar": 1839, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "HMO Salud Con Benefit Program", "standard_charge_dollar": 10640, "methodology": "case rate" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 2791.8, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 2791.8, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 2791.8, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 2791.8, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 2791.8, "methodology": "percent of total billed charges" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 2665, "methodology": "per diem" } ], "minimum": 850, "maximum": 10640 } ] }, { "description": "Room & Board - Deluxe Private - Medical/Surgical/GYN", "code_information": [ { "code": "0141", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 850, "methodology": "per diem" }, { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 2459, "methodology": "per diem" }, { "payer_name": "AltaMed", "plan_name": "Medi-Cal", "standard_charge_dollar": 2250, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3268.73, "methodology": "per diem" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Medi-Cal", "standard_charge_dollar": 1512.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Senior", "standard_charge_dollar": 3080.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Covered California (Qualified Health Plan)", "standard_charge_dollar": 1839, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "HMO Salud Con Benefit Program", "standard_charge_dollar": 10640, "methodology": "case rate" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 2665, "methodology": "per diem" } ], "minimum": 850, "maximum": 10640 } ] }, { "description": "Room & Board - Deluxe Private - Other", "code_information": [ { "code": "0149", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 850, "methodology": "per diem" }, { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 2459, "methodology": "per diem" }, { "payer_name": "AltaMed", "plan_name": "Medi-Cal", "standard_charge_dollar": 2250, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3268.73, "methodology": "per diem" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Medi-Cal", "standard_charge_dollar": 1512.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Senior", "standard_charge_dollar": 3080.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Covered California (Qualified Health Plan)", "standard_charge_dollar": 1839, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "HMO Salud Con Benefit Program", "standard_charge_dollar": 10640, "methodology": "case rate" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 2665, "methodology": "per diem" } ], "minimum": 850, "maximum": 10640 } ] }, { "description": "Room & Board - Ward - General Classification", "code_information": [ { "code": "0150", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 850, "methodology": "per diem" }, { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 2459, "methodology": "per diem" }, { "payer_name": "AltaMed", "plan_name": "Medi-Cal", "standard_charge_dollar": 2250, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3268.73, "methodology": "per diem" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Medi-Cal", "standard_charge_dollar": 1512.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Senior", "standard_charge_dollar": 3080.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Covered California (Qualified Health Plan)", "standard_charge_dollar": 1839, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "HMO Salud Con Benefit Program", "standard_charge_dollar": 10640, "methodology": "case rate" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 2665, "methodology": "per diem" } ], "minimum": 850, "maximum": 10640 } ] }, { "description": "Room & Board - Ward - Medical/Surgical/GYN", "code_information": [ { "code": "0151", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 850, "methodology": "per diem" }, { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 2459, "methodology": "per diem" }, { "payer_name": "AltaMed", "plan_name": "Medi-Cal", "standard_charge_dollar": 2250, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3268.73, "methodology": "per diem" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Medi-Cal", "standard_charge_dollar": 1512.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Senior", "standard_charge_dollar": 3080.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Covered California (Qualified Health Plan)", "standard_charge_dollar": 1839, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "HMO Salud Con Benefit Program", "standard_charge_dollar": 10640, "methodology": "case rate" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 2665, "methodology": "per diem" } ], "minimum": 850, "maximum": 10640 } ] }, { "description": "Room & Board - Ward - Other", "code_information": [ { "code": "0159", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 850, "methodology": "per diem" }, { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 2459, "methodology": "per diem" }, { "payer_name": "AltaMed", "plan_name": "Medi-Cal", "standard_charge_dollar": 2250, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3268.73, "methodology": "per diem" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Medi-Cal", "standard_charge_dollar": 1512.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Senior", "standard_charge_dollar": 3080.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Covered California (Qualified Health Plan)", "standard_charge_dollar": 1839, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "HMO Salud Con Benefit Program", "standard_charge_dollar": 10640, "methodology": "case rate" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 2665, "methodology": "per diem" } ], "minimum": 850, "maximum": 10640 } ] }, { "description": "Room & Board - Other - General Classification", "code_information": [ { "code": "0160", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 850, "methodology": "per diem" }, { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 2640, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 2459, "methodology": "per diem" }, { "payer_name": "AltaMed", "plan_name": "Medi-Cal", "standard_charge_dollar": 2250, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 3033, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3268.73, "methodology": "per diem" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Medi-Cal", "standard_charge_dollar": 1512.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Senior", "standard_charge_dollar": 3080.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Covered California (Qualified Health Plan)", "standard_charge_dollar": 1839, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "HMO Salud Con Benefit Program", "standard_charge_dollar": 10640, "methodology": "case rate" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2989, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 2665, "methodology": "per diem" } ], "minimum": 850, "maximum": 10640 } ] }, { "description": "ROOM & BOARD - HOSPITAL AT HOME", "code_information": [ { "code": "0161", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cal Optima", "plan_name": "Medi-Cal", "standard_charge_dollar": 850, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 3194, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 2459, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_dollar": 3268.73, "methodology": "per diem" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Medi-Cal", "standard_charge_dollar": 1512.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Senior", "standard_charge_dollar": 3080.5, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Covered California (Qualified Health Plan)", "standard_charge_dollar": 1839, "methodology": "per diem" }, { "payer_name": "Health Net of California", "plan_name": "HMO Salud Con Benefit Program", "standard_charge_dollar": 10640, "methodology": "case rate" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 2665, "methodology": "per diem" } ], "minimum": 850, "maximum": 10640 } ] }, { "description": "Skilled Nursing - Other", "code_information": [ { "code": "0559", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 1270, "methodology": "per diem" } ], "minimum": 1270, "maximum": 1270 } ] }, { "description": "Magnetic Resonance Technology (MRT) - Brain/Brainstem", "code_information": [ { "code": "0611", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 470, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_percentage": 55.300000000000004, "estimated_amount": 3532.4, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_percentage": 55.300000000000004, "estimated_amount": 3532.4, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_percentage": 55.300000000000004, "estimated_amount": 3532.4, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_percentage": 55.300000000000004, "estimated_amount": 3532.4, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 1379, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 1379, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 1379, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 1379, "methodology": "fee schedule" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_percentage": 45, "estimated_amount": 2874.47, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_percentage": 160, "estimated_amount": 10220.32, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_percentage": 160, "estimated_amount": 10220.32, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_percentage": 160, "estimated_amount": 10220.32, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_percentage": 160, "estimated_amount": 10220.32, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_percentage": 160, "estimated_amount": 10220.32, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_percentage": 160, "estimated_amount": 10220.32, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 2874.47, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 2874.47, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 2874.47, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 2874.47, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 2874.47, "methodology": "percent of total billed charges" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 470, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_percentage": 37.7, "estimated_amount": 2408.16, "methodology": "percent of total billed charges" }, { "payer_name": "Hispanic IPA", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 6387.7, "methodology": "percent of total billed charges" }, { "payer_name": "Accountable IPA", "plan_name": "Medi-Cal HMO", "standard_charge_percentage": 100, "estimated_amount": 6387.7, "methodology": "percent of total billed charges" }, { "payer_name": "Korean American Medical Group", "plan_name": "Korean American Medical Group (Delegated Entity)", "standard_charge_dollar": 650, "methodology": "case rate" } ], "minimum": 470, "maximum": 10220.32 } ] }, { "description": "Magnetic Resonance Technology (MRT) - Spinal Cord/Spine", "code_information": [ { "code": "0612", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 470, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_percentage": 55.300000000000004, "estimated_amount": 4105.42, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_percentage": 55.300000000000004, "estimated_amount": 4105.42, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_percentage": 55.300000000000004, "estimated_amount": 4105.42, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_percentage": 55.300000000000004, "estimated_amount": 4105.42, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 1379, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 1379, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 1379, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 1379, "methodology": "fee schedule" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_percentage": 45, "estimated_amount": 3340.76, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_percentage": 160, "estimated_amount": 11878.24, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_percentage": 160, "estimated_amount": 11878.24, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_percentage": 160, "estimated_amount": 11878.24, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_percentage": 160, "estimated_amount": 11878.24, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_percentage": 160, "estimated_amount": 11878.24, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_percentage": 160, "estimated_amount": 11878.24, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 3340.76, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 3340.76, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 3340.76, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 3340.76, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 3340.76, "methodology": "percent of total billed charges" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 470, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_percentage": 37.7, "estimated_amount": 2798.81, "methodology": "percent of total billed charges" }, { "payer_name": "Hispanic IPA", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 7423.9, "methodology": "percent of total billed charges" }, { "payer_name": "Accountable IPA", "plan_name": "Medi-Cal HMO", "standard_charge_percentage": 100, "estimated_amount": 7423.9, "methodology": "percent of total billed charges" }, { "payer_name": "Korean American Medical Group", "plan_name": "Korean American Medical Group (Delegated Entity)", "standard_charge_dollar": 650, "methodology": "case rate" } ], "minimum": 470, "maximum": 11878.24 } ] }, { "description": "Magnetic Resonance Technology (MRT) - MRI - Other", "code_information": [ { "code": "0614", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 470, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_percentage": 55.300000000000004, "estimated_amount": 1873.56, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_percentage": 55.300000000000004, "estimated_amount": 1873.56, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_percentage": 55.300000000000004, "estimated_amount": 1873.56, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_percentage": 55.300000000000004, "estimated_amount": 1873.56, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 1379, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 1379, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 1379, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 1379, "methodology": "fee schedule" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_percentage": 45, "estimated_amount": 1524.6, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_percentage": 160, "estimated_amount": 5420.8, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_percentage": 160, "estimated_amount": 5420.8, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_percentage": 160, "estimated_amount": 5420.8, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_percentage": 160, "estimated_amount": 5420.8, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_percentage": 160, "estimated_amount": 5420.8, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_percentage": 160, "estimated_amount": 5420.8, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 1524.6, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 1524.6, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 1524.6, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 1524.6, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 1524.6, "methodology": "percent of total billed charges" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 470, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_percentage": 37.7, "estimated_amount": 1277.28, "methodology": "percent of total billed charges" }, { "payer_name": "Hispanic IPA", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 3388, "methodology": "percent of total billed charges" }, { "payer_name": "Accountable IPA", "plan_name": "Medi-Cal HMO", "standard_charge_percentage": 100, "estimated_amount": 3388, "methodology": "percent of total billed charges" }, { "payer_name": "Korean American Medical Group", "plan_name": "Korean American Medical Group (Delegated Entity)", "standard_charge_dollar": 650, "methodology": "case rate" } ], "minimum": 470, "maximum": 5420.8 } ] }, { "description": "Magnetic Resonance Technology (MRT) - MRA - Head and Neck", "code_information": [ { "code": "0615", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 470, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_percentage": 55.300000000000004, "estimated_amount": 4079.26, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_percentage": 55.300000000000004, "estimated_amount": 4079.26, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_percentage": 55.300000000000004, "estimated_amount": 4079.26, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_percentage": 55.300000000000004, "estimated_amount": 4079.26, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 1379, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 1379, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 1379, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 1379, "methodology": "fee schedule" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_percentage": 45, "estimated_amount": 3319.47, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_percentage": 160, "estimated_amount": 11802.56, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_percentage": 160, "estimated_amount": 11802.56, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_percentage": 160, "estimated_amount": 11802.56, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_percentage": 160, "estimated_amount": 11802.56, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_percentage": 160, "estimated_amount": 11802.56, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_percentage": 160, "estimated_amount": 11802.56, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 3319.47, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 3319.47, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 3319.47, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 3319.47, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 3319.47, "methodology": "percent of total billed charges" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 470, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_percentage": 37.7, "estimated_amount": 2780.98, "methodology": "percent of total billed charges" }, { "payer_name": "Hispanic IPA", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 7376.6, "methodology": "percent of total billed charges" }, { "payer_name": "Accountable IPA", "plan_name": "Medi-Cal HMO", "standard_charge_percentage": 100, "estimated_amount": 7376.6, "methodology": "percent of total billed charges" }, { "payer_name": "Korean American Medical Group", "plan_name": "Korean American Medical Group (Delegated Entity)", "standard_charge_dollar": 650, "methodology": "case rate" } ], "minimum": 470, "maximum": 11802.56 } ] }, { "description": "Magnetic Resonance Technology (MRT) - MRA - Lower Extremities", "code_information": [ { "code": "0616", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 470, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_percentage": 55.300000000000004, "estimated_amount": 2545.13, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_percentage": 55.300000000000004, "estimated_amount": 2545.13, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_percentage": 55.300000000000004, "estimated_amount": 2545.13, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_percentage": 55.300000000000004, "estimated_amount": 2545.13, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 1379, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 1379, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 1379, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 1379, "methodology": "fee schedule" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_percentage": 45, "estimated_amount": 2071.08, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_percentage": 160, "estimated_amount": 7363.84, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_percentage": 160, "estimated_amount": 7363.84, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_percentage": 160, "estimated_amount": 7363.84, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_percentage": 160, "estimated_amount": 7363.84, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_percentage": 160, "estimated_amount": 7363.84, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_percentage": 160, "estimated_amount": 7363.84, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 2071.08, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 2071.08, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 2071.08, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 2071.08, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 2071.08, "methodology": "percent of total billed charges" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 470, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_percentage": 37.7, "estimated_amount": 1735.1, "methodology": "percent of total billed charges" }, { "payer_name": "Hispanic IPA", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 4602.4, "methodology": "percent of total billed charges" }, { "payer_name": "Accountable IPA", "plan_name": "Medi-Cal HMO", "standard_charge_percentage": 100, "estimated_amount": 4602.4, "methodology": "percent of total billed charges" }, { "payer_name": "Korean American Medical Group", "plan_name": "Korean American Medical Group (Delegated Entity)", "standard_charge_dollar": 650, "methodology": "case rate" } ], "minimum": 470, "maximum": 7363.84 } ] }, { "description": "Magnetic Resonance Technology (MRT) - MRA - Other", "code_information": [ { "code": "0618", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 470, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_percentage": 55.300000000000004, "estimated_amount": 2545.13, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_percentage": 55.300000000000004, "estimated_amount": 2545.13, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_percentage": 55.300000000000004, "estimated_amount": 2545.13, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_percentage": 55.300000000000004, "estimated_amount": 2545.13, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 1379, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 1379, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 1379, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 1379, "methodology": "fee schedule" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_percentage": 45, "estimated_amount": 2071.08, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_percentage": 160, "estimated_amount": 7363.84, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_percentage": 160, "estimated_amount": 7363.84, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_percentage": 160, "estimated_amount": 7363.84, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_percentage": 160, "estimated_amount": 7363.84, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_percentage": 160, "estimated_amount": 7363.84, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_percentage": 160, "estimated_amount": 7363.84, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 2071.08, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 2071.08, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 2071.08, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 2071.08, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 2071.08, "methodology": "percent of total billed charges" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 470, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_percentage": 37.7, "estimated_amount": 1735.1, "methodology": "percent of total billed charges" }, { "payer_name": "Hispanic IPA", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 4602.4, "methodology": "percent of total billed charges" }, { "payer_name": "Accountable IPA", "plan_name": "Medi-Cal HMO", "standard_charge_percentage": 100, "estimated_amount": 4602.4, "methodology": "percent of total billed charges" }, { "payer_name": "Korean American Medical Group", "plan_name": "Korean American Medical Group (Delegated Entity)", "standard_charge_dollar": 650, "methodology": "case rate" } ], "minimum": 470, "maximum": 7363.84 } ] }, { "description": "Magnetic Resonance Technology (MRT) - Other", "code_information": [ { "code": "0619", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 470, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 1379, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 1379, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 1379, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 1379, "methodology": "fee schedule" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 470, "methodology": "fee schedule" }, { "payer_name": "Korean American Medical Group", "plan_name": "Korean American Medical Group (Delegated Entity)", "standard_charge_dollar": 650, "methodology": "case rate" } ], "minimum": 470, "maximum": 1379 } ] }, { "description": "Medical Surgical Supplies - Incident to Radiology", "code_information": [ { "code": "0621", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 65.84, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 65.84, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 65.84, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 65.84, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 65.84, "methodology": "percent of total billed charges" } ], "minimum": 65.84, "maximum": 65.84 } ] }, { "description": "Medical Surgical Supplies - Incident to Other Diagnostic Services", "code_information": [ { "code": "0622", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 30.69, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 30.69, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 30.69, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 30.69, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 30.69, "methodology": "percent of total billed charges" } ], "minimum": 30.69, "maximum": 30.69 } ] }, { "description": "Pharmacy - Erythropoietin (EPO) less than 10,000 units", "code_information": [ { "code": "0634", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 2.97, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 2.97, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 2.97, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 2.97, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 2.97, "methodology": "percent of total billed charges" } ], "minimum": 2.97, "maximum": 2.97 } ] }, { "description": "Pharmacy - Drugs Requiring Detailed Coding", "code_information": [ { "code": "0636", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_percentage": 35.4, "estimated_amount": 156.54, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_percentage": 35.4, "estimated_amount": 156.54, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_percentage": 35.4, "estimated_amount": 156.54, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_percentage": 35.4, "estimated_amount": 156.54, "methodology": "percent of total billed charges" }, { "payer_name": "AltaMed", "plan_name": "Medi-Cal", "standard_charge_percentage": 35, "estimated_amount": 154.77, "methodology": "percent of total billed charges" }, { "payer_name": "Molina", "plan_name": "Medi-Cal Two-Plan Model", "standard_charge_percentage": 18, "estimated_amount": 79.6, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_percentage": 38.92, "estimated_amount": 172.1, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_percentage": 38.92, "estimated_amount": 172.1, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_percentage": 38.92, "estimated_amount": 172.1, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_percentage": 38.92, "estimated_amount": 172.1, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_percentage": 38.92, "estimated_amount": 172.1, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_percentage": 38.92, "estimated_amount": 172.1, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 198.99, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 198.99, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 198.99, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 198.99, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 198.99, "methodology": "percent of total billed charges" }, { "payer_name": "Heritage Provider Network", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 442.2, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_percentage": 33.4, "estimated_amount": 147.69, "methodology": "percent of total billed charges" }, { "payer_name": "Hispanic IPA", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 442.2, "methodology": "percent of total billed charges" }, { "payer_name": "Accountable IPA", "plan_name": "Medi-Cal HMO", "standard_charge_percentage": 100, "estimated_amount": 442.2, "methodology": "percent of total billed charges" }, { "payer_name": "K-Day", "plan_name": "PACE", "standard_charge_percentage": 35, "estimated_amount": 154.77, "methodology": "percent of total billed charges" } ], "minimum": 79.6, "maximum": 442.2 } ] }, { "description": "Pharmacy - Self-administrable Drugs", "code_information": [ { "code": "0637", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 13.37, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 13.37, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 13.37, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 13.37, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 13.37, "methodology": "percent of total billed charges" } ], "minimum": 13.37, "maximum": 13.37 } ] }, { "description": "Recovery Room - General Classification", "code_information": [ { "code": "0710", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_percentage": 45, "estimated_amount": 487.58, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 487.58, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 487.58, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 487.58, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 487.58, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 487.58, "methodology": "percent of total billed charges" }, { "payer_name": "Hispanic IPA", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 1083.5, "methodology": "percent of total billed charges" } ], "minimum": 487.58, "maximum": 1083.5 } ] }, { "description": "Labor Room/Delivery - Labor", "code_information": [ { "code": "0721", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 315, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 315, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 315, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 315, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 315, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 358, "methodology": "fee schedule" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 145.04, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 145.04, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 145.04, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 145.04, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 145.04, "methodology": "percent of total billed charges" } ], "minimum": 145.04, "maximum": 358 } ] }, { "description": "Labor Room/Delivery - Delivery Room", "code_information": [ { "code": "0722", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 315, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 315, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 315, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 315, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 315, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 358, "methodology": "fee schedule" } ], "minimum": 315, "maximum": 358 } ] }, { "description": "Labor Room/Delivery - Other", "code_information": [ { "code": "0729", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 315, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 315, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 315, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 315, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 315, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 358, "methodology": "fee schedule" } ], "minimum": 315, "maximum": 358 } ] }, { "description": "Gastro-Intestinal (GI) Services - General Classification", "code_information": [ { "code": "0750", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_percentage": 37.5, "estimated_amount": 1085.29, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 5625, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 5625, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 5625, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 5625, "methodology": "case rate" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_percentage": 45, "estimated_amount": 1302.35, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 13879, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 13879, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 13879, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 13879, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 13879, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 6157, "methodology": "case rate" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 1302.35, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 1302.35, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 1302.35, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 1302.35, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 1302.35, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_percentage": 37.7, "estimated_amount": 1091.08, "methodology": "percent of total billed charges" }, { "payer_name": "Hispanic IPA", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 2894.1, "methodology": "percent of total billed charges" }, { "payer_name": "Accountable IPA", "plan_name": "Medi-Cal HMO", "standard_charge_percentage": 100, "estimated_amount": 2894.1, "methodology": "percent of total billed charges" } ], "minimum": 1085.29, "maximum": 13879 } ] }, { "description": "Specialty Services - General Classification", "code_information": [ { "code": "0760", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_percentage": 70, "estimated_amount": 345.73, "methodology": "percent of total billed charges" }, { "payer_name": "Prospect Health Plan", "plan_name": "Commercial/POS/Exchange", "standard_charge_dollar": 3300, "methodology": "per diem" }, { "payer_name": "Prospect Health Plan", "plan_name": "Medi-Cal", "standard_charge_dollar": 1200, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_percentage": 34.4, "estimated_amount": 169.9, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_percentage": 34.4, "estimated_amount": 169.9, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_percentage": 34.4, "estimated_amount": 169.9, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_percentage": 34.4, "estimated_amount": 169.9, "methodology": "fee schedule" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_percentage": 45, "estimated_amount": 222.26, "methodology": "percent of total billed charges" }, { "payer_name": "Heritage Provider Network", "plan_name": "Senior", "standard_charge_percentage": 45, "estimated_amount": 222.26, "methodology": "percent of total billed charges" }, { "payer_name": "Prospect Health Plan", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2000, "methodology": "per diem" }, { "payer_name": "Prospect Health Plan", "plan_name": "Medi-Medi", "standard_charge_dollar": 2000, "methodology": "per diem" }, { "payer_name": "Prospect Health Plan", "plan_name": "Dual Eligible Special Needs Plans (D-SNP)", "standard_charge_dollar": 2000, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Covered California (Qualified Health Plan)", "standard_charge_percentage": 40, "estimated_amount": 197.56, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 222.26, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 222.26, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 222.26, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 222.26, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 222.26, "methodology": "percent of total billed charges" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_percentage": 70, "estimated_amount": 345.73, "methodology": "percent of total billed charges" }, { "payer_name": "Hispanic IPA", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 493.9, "methodology": "percent of total billed charges" }, { "payer_name": "Accountable IPA", "plan_name": "Medi-Cal HMO", "standard_charge_percentage": 100, "estimated_amount": 493.9, "methodology": "percent of total billed charges" } ], "minimum": 169.9, "maximum": 3300 } ] }, { "description": "Specialty Services - Treatment Room", "code_information": [ { "code": "0761", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Prospect Health Plan", "plan_name": "Commercial/POS/Exchange", "standard_charge_dollar": 3300, "methodology": "per diem" }, { "payer_name": "Prospect Health Plan", "plan_name": "Medi-Cal", "standard_charge_dollar": 1200, "methodology": "per diem" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 5625, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 5625, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 5625, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 5625, "methodology": "case rate" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_percentage": 45, "estimated_amount": 164.34, "methodology": "percent of total billed charges" }, { "payer_name": "Heritage Provider Network", "plan_name": "Senior", "standard_charge_percentage": 45, "estimated_amount": 164.34, "methodology": "percent of total billed charges" }, { "payer_name": "Prospect Health Plan", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2000, "methodology": "per diem" }, { "payer_name": "Prospect Health Plan", "plan_name": "Medi-Medi", "standard_charge_dollar": 2000, "methodology": "per diem" }, { "payer_name": "Prospect Health Plan", "plan_name": "Dual Eligible Special Needs Plans (D-SNP)", "standard_charge_dollar": 2000, "methodology": "per diem" }, { "payer_name": "Heritage Provider Network", "plan_name": "Covered California (Qualified Health Plan)", "standard_charge_percentage": 40, "estimated_amount": 146.08, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 164.34, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 164.34, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 164.34, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 164.34, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 164.34, "methodology": "percent of total billed charges" }, { "payer_name": "Hispanic IPA", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 365.2, "methodology": "percent of total billed charges" }, { "payer_name": "Accountable IPA", "plan_name": "Medi-Cal HMO", "standard_charge_percentage": 100, "estimated_amount": 365.2, "methodology": "percent of total billed charges" } ], "minimum": 146.08, "maximum": 5625 } ] }, { "description": "Specialty Services - Observation Hours", "code_information": [ { "code": "0762", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_percentage": 70, "estimated_amount": 143.22, "methodology": "percent of total billed charges" }, { "payer_name": "Prospect Health Plan", "plan_name": "Commercial/POS/Exchange", "standard_charge_dollar": 3300, "methodology": "per diem" }, { "payer_name": "Prospect Health Plan", "plan_name": "Medi-Cal", "standard_charge_dollar": 1200, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 2871.75, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 2871.75, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 2871.75, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 2871.75, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_percentage": 34.4, "estimated_amount": 73.03, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_percentage": 34.4, "estimated_amount": 73.03, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_percentage": 34.4, "estimated_amount": 73.03, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_percentage": 34.4, "estimated_amount": 73.03, "methodology": "fee schedule" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_percentage": 45, "estimated_amount": 92.07, "methodology": "percent of total billed charges" }, { "payer_name": "Heritage Provider Network", "plan_name": "Senior", "standard_charge_percentage": 45, "estimated_amount": 92.07, "methodology": "percent of total billed charges" }, { "payer_name": "Prospect Health Plan", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2000, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 1377, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 1377, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 1377, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 1377, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 1377, "methodology": "case rate" }, { "payer_name": "Prospect Health Plan", "plan_name": "Medi-Medi", "standard_charge_dollar": 2000, "methodology": "per diem" }, { "payer_name": "Prospect Health Plan", "plan_name": "Dual Eligible Special Needs Plans (D-SNP)", "standard_charge_dollar": 2000, "methodology": "per diem" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1491, "methodology": "case rate" }, { "payer_name": "Heritage Provider Network", "plan_name": "Covered California (Qualified Health Plan)", "standard_charge_percentage": 40, "estimated_amount": 81.84, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 92.07, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 92.07, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 92.07, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 92.07, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 92.07, "methodology": "percent of total billed charges" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_percentage": 70, "estimated_amount": 143.22, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem", "plan_name": "Medi-Cal Managed Care", "standard_charge_dollar": 30, "methodology": "fee schedule" }, { "payer_name": "Hispanic IPA", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 204.6, "methodology": "percent of total billed charges" }, { "payer_name": "Accountable IPA", "plan_name": "Medi-Cal HMO", "standard_charge_percentage": 100, "estimated_amount": 204.6, "methodology": "percent of total billed charges" } ], "minimum": 30, "maximum": 3300 } ] }, { "description": "Preventive Care Services - Vaccine Administration", "code_information": [ { "code": "0771", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_percentage": 45, "estimated_amount": 77.96, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 195, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 195, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 195, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 195, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 195, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 219, "methodology": "fee schedule" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 77.96, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 77.96, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 77.96, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 77.96, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 77.96, "methodology": "percent of total billed charges" }, { "payer_name": "Hispanic IPA", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 173.25, "methodology": "percent of total billed charges" }, { "payer_name": "Accountable IPA", "plan_name": "Medi-Cal HMO", "standard_charge_percentage": 100, "estimated_amount": 173.25, "methodology": "percent of total billed charges" } ], "minimum": 77.96, "maximum": 219 } ] }, { "description": "Extra-Corporeal Shock Wave Therapy - General Classification", "code_information": [ { "code": "0790", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 9174, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 5625, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 5625, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 5625, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 5625, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 13879, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 13879, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 13879, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 13879, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 13879, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 6157, "methodology": "case rate" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 6695.87, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 6695.87, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 6695.87, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 6695.87, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 6695.87, "methodology": "percent of total billed charges" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 9174, "methodology": "fee schedule" } ], "minimum": 5625, "maximum": 13879 } ] }, { "description": "Inpatient Renal Dialysis - Hemodialysis", "code_information": [ { "code": "0801", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 630, "methodology": "fee schedule" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 1231.56, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 1231.56, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 1231.56, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 1231.56, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 1231.56, "methodology": "percent of total billed charges" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 630, "methodology": "fee schedule" } ], "minimum": 630, "maximum": 1231.56 } ] }, { "description": "Inpatient Renal Dialysis - Peritoneal Dialysis (Non-CAPD)", "code_information": [ { "code": "0802", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 630, "methodology": "fee schedule" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 630, "methodology": "fee schedule" } ], "minimum": 630, "maximum": 630 } ] }, { "description": "Inpatient Renal Dialysis - Continuous Cycling Peritoneal Dialysis (CCPD)", "code_information": [ { "code": "0804", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 630, "methodology": "fee schedule" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 630, "methodology": "fee schedule" } ], "minimum": 630, "maximum": 630 } ] }, { "description": "Inpatient Renal Dialysis - Other", "code_information": [ { "code": "0809", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 630, "methodology": "fee schedule" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 630, "methodology": "fee schedule" } ], "minimum": 630, "maximum": 630 } ] }, { "description": "Acquisition of Body Components - General Classification", "code_information": [ { "code": "0810", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 3915, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 3915, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 3915, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 3915, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 3915, "methodology": "percent of total billed charges" } ], "minimum": 3915, "maximum": 3915 } ] }, { "description": "Hemodialysis - Outpatient or Home - General Classification", "code_information": [ { "code": "0820", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 693, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1621, "methodology": "fee schedule" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 630, "methodology": "fee schedule" } ], "minimum": 630, "maximum": 1621 } ] }, { "description": "Hemodialysis - Outpatient or Home - Hemodialysis Composite or Other Rate", "code_information": [ { "code": "0821", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 693, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1621, "methodology": "fee schedule" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 630, "methodology": "fee schedule" } ], "minimum": 630, "maximum": 1621 } ] }, { "description": "Hemodialysis - Outpatient or Home - Home Supplies", "code_information": [ { "code": "0822", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1621, "methodology": "fee schedule" } ], "minimum": 1439, "maximum": 1621 } ] }, { "description": "Hemodialysis - Outpatient or Home - Home Equipment", "code_information": [ { "code": "0823", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1621, "methodology": "fee schedule" } ], "minimum": 1439, "maximum": 1621 } ] }, { "description": "Hemodialysis - Outpatient or Home - Maintenance 100%", "code_information": [ { "code": "0824", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1621, "methodology": "fee schedule" } ], "minimum": 1439, "maximum": 1621 } ] }, { "description": "Hemodialysis - Outpatient or Home - Support Services", "code_information": [ { "code": "0825", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1621, "methodology": "fee schedule" } ], "minimum": 1439, "maximum": 1621 } ] }, { "description": "Hemodialysis - Outpatient or Home - Other OP Hemodialysis", "code_information": [ { "code": "0829", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 693, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_percentage": 50.6, "estimated_amount": 2393.38, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_percentage": 50.6, "estimated_amount": 2393.38, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_percentage": 50.6, "estimated_amount": 2393.38, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_percentage": 50.6, "estimated_amount": 2393.38, "methodology": "percent of total billed charges" }, { "payer_name": "Heritage Provider Network", "plan_name": "Commercial", "standard_charge_percentage": 45, "estimated_amount": 2128.5, "methodology": "percent of total billed charges" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 1439, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1621, "methodology": "fee schedule" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Bronze", "standard_charge_percentage": 45, "estimated_amount": 2128.5, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell 7030", "standard_charge_percentage": 45, "estimated_amount": 2128.5, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold 12", "standard_charge_percentage": 45, "estimated_amount": 2128.5, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Gold", "standard_charge_percentage": 45, "estimated_amount": 2128.5, "methodology": "percent of total billed charges" }, { "payer_name": "Guam StayWell", "plan_name": "StayWell Silver", "standard_charge_percentage": 45, "estimated_amount": 2128.5, "methodology": "percent of total billed charges" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 630, "methodology": "fee schedule" }, { "payer_name": "Hispanic IPA", "plan_name": "Medi-Cal", "standard_charge_percentage": 100, "estimated_amount": 4730, "methodology": "percent of total billed charges" }, { "payer_name": "Accountable IPA", "plan_name": "Medi-Cal HMO", "standard_charge_percentage": 100, "estimated_amount": 4730, "methodology": "percent of total billed charges" } ], "minimum": 630, "maximum": 4730 } ] }, { "description": "Peritoneal Dialysis - Outpatient or Home - General Classification", "code_information": [ { "code": "0830", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1059, "methodology": "fee schedule" } ], "minimum": 940, "maximum": 1059 } ] }, { "description": "Peritoneal Dialysis - Outpatient or Home - Peritoneal/Composite or Other Rate", "code_information": [ { "code": "0831", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1059, "methodology": "fee schedule" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 630, "methodology": "fee schedule" } ], "minimum": 630, "maximum": 1059 } ] }, { "description": "Peritoneal Dialysis - Outpatient or Home - Home Supplies", "code_information": [ { "code": "0832", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1059, "methodology": "fee schedule" } ], "minimum": 940, "maximum": 1059 } ] }, { "description": "Peritoneal Dialysis - Outpatient or Home - Home Equipment", "code_information": [ { "code": "0833", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1059, "methodology": "fee schedule" } ], "minimum": 940, "maximum": 1059 } ] }, { "description": "Peritoneal Dialysis - Outpatient or Home - Maintenance 100%", "code_information": [ { "code": "0834", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1059, "methodology": "fee schedule" } ], "minimum": 940, "maximum": 1059 } ] }, { "description": "Peritoneal Dialysis - Outpatient or Home - Support Services", "code_information": [ { "code": "0835", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1059, "methodology": "fee schedule" } ], "minimum": 940, "maximum": 1059 } ] }, { "description": "Peritoneal Dialysis - Outpatient or Home - Other", "code_information": [ { "code": "0839", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1059, "methodology": "fee schedule" } ], "minimum": 940, "maximum": 1059 } ] }, { "description": "Continuous Ambulatory Peritoneal Dialysis (CAPD) - Outpatient or Home - General Classification", "code_information": [ { "code": "0840", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1059, "methodology": "fee schedule" } ], "minimum": 940, "maximum": 1059 } ] }, { "description": "Continuous Ambulatory Peritoneal Dialysis (CAPD) - Outpatient or Home - CAPD/Composite or Other Rate", "code_information": [ { "code": "0841", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1059, "methodology": "fee schedule" } ], "minimum": 940, "maximum": 1059 } ] }, { "description": "Continuous Ambulatory Peritoneal Dialysis (CAPD) - Outpatient or Home - Home Supplies", "code_information": [ { "code": "0842", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1059, "methodology": "fee schedule" } ], "minimum": 940, "maximum": 1059 } ] }, { "description": "Continuous Ambulatory Peritoneal Dialysis (CAPD) - Outpatient or Home - Home Equipment", "code_information": [ { "code": "0843", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1059, "methodology": "fee schedule" } ], "minimum": 940, "maximum": 1059 } ] }, { "description": "Continuous Ambulatory Peritoneal Dialysis (CAPD) - Outpatient or Home - Maintenance 100%", "code_information": [ { "code": "0844", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1059, "methodology": "fee schedule" } ], "minimum": 940, "maximum": 1059 } ] }, { "description": "Continuous Ambulatory Peritoneal Dialysis (CAPD) - Outpatient or Home - Support Services", "code_information": [ { "code": "0845", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1059, "methodology": "fee schedule" } ], "minimum": 940, "maximum": 1059 } ] }, { "description": "Continuous Ambulatory Peritoneal Dialysis (CAPD) - Outpatient or Home - Other", "code_information": [ { "code": "0849", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1059, "methodology": "fee schedule" } ], "minimum": 940, "maximum": 1059 } ] }, { "description": "Continuous Cycling Peritoneal Dialysis (CCPD) - Outpatient or Home - General Classification", "code_information": [ { "code": "0850", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1059, "methodology": "fee schedule" } ], "minimum": 940, "maximum": 1059 } ] }, { "description": "Continuous Cycling Peritoneal Dialysis (CCPD) - Outpatient or Home - CCPD/Composite or Other Rate", "code_information": [ { "code": "0851", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1059, "methodology": "fee schedule" } ], "minimum": 940, "maximum": 1059 } ] }, { "description": "Continuous Cycling Peritoneal Dialysis (CCPD) - Outpatient or Home - Home Supplies", "code_information": [ { "code": "0852", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1059, "methodology": "fee schedule" } ], "minimum": 940, "maximum": 1059 } ] }, { "description": "Continuous Cycling Peritoneal Dialysis (CCPD) - Outpatient or Home - Home Equipment", "code_information": [ { "code": "0853", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1059, "methodology": "fee schedule" } ], "minimum": 940, "maximum": 1059 } ] }, { "description": "Continuous Cycling Peritoneal Dialysis (CCPD) - Outpatient or Home - Maintenance 100%", "code_information": [ { "code": "0854", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1059, "methodology": "fee schedule" } ], "minimum": 940, "maximum": 1059 } ] }, { "description": "Continuous Cycling Peritoneal Dialysis (CCPD) - Outpatient or Home - Support Services", "code_information": [ { "code": "0855", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1059, "methodology": "fee schedule" } ], "minimum": 940, "maximum": 1059 } ] }, { "description": "Continuous Cycling Peritoneal Dialysis (CCPD) - Outpatient or Home - Other", "code_information": [ { "code": "0859", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 940, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 1059, "methodology": "fee schedule" } ], "minimum": 940, "maximum": 1059 } ] }, { "description": "Intracranial Hemorrhage or Cerebral Infarction with MCC", "code_information": [ { "code": "064", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Alta Hospital Systems", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 16789.26, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "HMO", "standard_charge_percentage": 120, "estimated_amount": 20147.11, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 16789.26, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 16789.26, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "DSNP", "standard_charge_percentage": 100, "estimated_amount": 16789.26, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Self-Funded EPO/PPO", "standard_charge_percentage": 120, "estimated_amount": 20147.11, "methodology": "fee schedule" }, { "payer_name": "New Century Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 16789.26, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "L.A. Care Covered California", "standard_charge_percentage": 114.99999999999999, "estimated_amount": 19307.65, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Senior HMO", "standard_charge_percentage": 100, "estimated_amount": 16789.26, "methodology": "fee schedule" }, { "payer_name": "Alignment", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 16789.26, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 16789.26, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Duals", "standard_charge_percentage": 100, "estimated_amount": 16789.26, "methodology": "fee schedule" }, { "payer_name": "Pipeline formerly Avanti", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 16789.26, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 16789.26, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 16789.26, "methodology": "fee schedule" }, { "payer_name": "Imperial Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 16789.26, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 16789.26, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "C-SNP (Chronic Special Needs Plan)", "standard_charge_percentage": 100, "estimated_amount": 16789.26, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN Network", "standard_charge_percentage": 100, "estimated_amount": 17369.28, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 16789.26, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Special Needs Plan (SNP)", "standard_charge_percentage": 100, "estimated_amount": 16789.26, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Medicare Advantage Prescription Drug (MAPD)", "standard_charge_percentage": 100, "estimated_amount": 16789.26, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 16789.26, "methodology": "fee schedule" }, { "payer_name": "Access Senior Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 16789.26, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 16789.26, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 19965.94, "methodology": "fee schedule" }, { "payer_name": "AltaMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 16789.26, "methodology": "fee schedule" }, { "payer_name": "Clever Care Health", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "estimated_amount": 16789.26, "methodology": "fee schedule" }, { "payer_name": "Anthem", "plan_name": "Medicare Advantage", "standard_charge_percentage": 106, "estimated_amount": 17796.62, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 16789.26, "methodology": "fee schedule" }, { "payer_name": "California State Prison", "plan_name": "Prison Healthcare Provider Network Project", "standard_charge_percentage": 125, "estimated_amount": 20986.58, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 16789.26, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Commercial", "standard_charge_percentage": 130, "estimated_amount": 21826.04, "methodology": "fee schedule" }, { "payer_name": "Medicare", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 16789.26, "methodology": "fee schedule" }, { "payer_name": "K-Day", "plan_name": "PACE", "standard_charge_percentage": 100, "estimated_amount": 16789.26, "methodology": "fee schedule" } ], "minimum": 16789.26, "maximum": 21826.04 } ] }, { "description": "Intracranial Hemorrhage or Cerebral Infarction with CC or TPA in 24 Hours", "code_information": [ { "code": "065", "type": 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Care Covered California", "standard_charge_percentage": 114.99999999999999, "estimated_amount": 9797.45, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Senior HMO", "standard_charge_percentage": 100, "estimated_amount": 8519.52, "methodology": "fee schedule" }, { "payer_name": "Alignment", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 8519.52, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 8519.52, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Duals", "standard_charge_percentage": 100, "estimated_amount": 8519.52, "methodology": "fee schedule" }, { "payer_name": "Pipeline formerly Avanti", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 8519.52, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 8519.52, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 8519.52, "methodology": "fee schedule" }, { "payer_name": "Imperial Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 8519.52, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 8519.52, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "C-SNP (Chronic Special Needs Plan)", "standard_charge_percentage": 100, "estimated_amount": 8519.52, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN Network", "standard_charge_percentage": 100, "estimated_amount": 8875.96, "methodology": "fee schedule" }, { 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"plan_name": "Medicare Advantage", "standard_charge_percentage": 106, "estimated_amount": 246095.26, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 232165.34, "methodology": "fee schedule" }, { "payer_name": "California State Prison", "plan_name": "Prison Healthcare Provider Network Project", "standard_charge_percentage": 125, "estimated_amount": 290206.68, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 232165.34, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Commercial", "standard_charge_percentage": 130, "estimated_amount": 301814.94, "methodology": "fee schedule" }, { "payer_name": "Medicare", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 232165.34, "methodology": "fee schedule" }, { "payer_name": "K-Day", "plan_name": "PACE", "standard_charge_percentage": 100, "estimated_amount": 232165.34, "methodology": "fee schedule" } ], "minimum": 232165.34, "maximum": 301814.94 } ] }, { "description": "Heart Transplant or Implant of Heart Assist System without MCC", "code_information": [ { "code": "002", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Alta Hospital Systems", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 102630.76, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "HMO", "standard_charge_percentage": 120, "estimated_amount": 123156.91, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 102630.76, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 102630.76, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "DSNP", "standard_charge_percentage": 100, "estimated_amount": 102630.76, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Self-Funded EPO/PPO", "standard_charge_percentage": 120, "estimated_amount": 123156.91, "methodology": "fee schedule" }, { "payer_name": "New Century Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 102630.76, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "L.A. Care Covered California", "standard_charge_percentage": 114.99999999999999, "estimated_amount": 118025.37, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Senior HMO", "standard_charge_percentage": 100, "estimated_amount": 102630.76, "methodology": "fee schedule" }, { "payer_name": "Alignment", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 102630.76, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 102630.76, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Duals", "standard_charge_percentage": 100, "estimated_amount": 102630.76, "methodology": "fee schedule" }, { "payer_name": "Pipeline formerly Avanti", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 102630.76, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 102630.76, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 102630.76, "methodology": "fee schedule" }, { "payer_name": "Imperial Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 102630.76, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 102630.76, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "C-SNP (Chronic Special Needs Plan)", "standard_charge_percentage": 100, "estimated_amount": 102630.76, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN Network", "standard_charge_percentage": 100, "estimated_amount": 83477.08, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 102630.76, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Special Needs Plan (SNP)", "standard_charge_percentage": 100, "estimated_amount": 102630.76, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Medicare Advantage Prescription Drug (MAPD)", "standard_charge_percentage": 100, "estimated_amount": 102630.76, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 102630.76, "methodology": "fee schedule" }, { "payer_name": "Access Senior Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 102630.76, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 102630.76, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 95956.69, "methodology": "fee schedule" }, { "payer_name": "AltaMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 102630.76, "methodology": "fee schedule" }, { "payer_name": "Clever Care Health", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "estimated_amount": 102630.76, "methodology": "fee schedule" }, { "payer_name": "Anthem", "plan_name": "Medicare Advantage", "standard_charge_percentage": 106, "estimated_amount": 108788.61, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 102630.76, "methodology": "fee schedule" }, { "payer_name": "California State Prison", "plan_name": "Prison Healthcare Provider Network Project", "standard_charge_percentage": 125, "estimated_amount": 128288.45, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 102630.76, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Commercial", "standard_charge_percentage": 130, "estimated_amount": 133419.99, "methodology": "fee schedule" }, { "payer_name": "Medicare", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 102630.76, "methodology": "fee schedule" }, { "payer_name": "K-Day", "plan_name": "PACE", "standard_charge_percentage": 100, "estimated_amount": 102630.76, "methodology": "fee schedule" } ], "minimum": 83477.08, "maximum": 133419.99 } ] }, { "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", "payers_information": [ { "payer_name": "Alta Hospital Systems", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 178707.99, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "HMO", "standard_charge_percentage": 120, "estimated_amount": 214449.59, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 178707.99, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 178707.99, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "DSNP", "standard_charge_percentage": 100, "estimated_amount": 178707.99, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Self-Funded EPO/PPO", "standard_charge_percentage": 120, "estimated_amount": 214449.59, "methodology": "fee schedule" }, { "payer_name": "New Century Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 178707.99, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "L.A. Care Covered California", "standard_charge_percentage": 114.99999999999999, "estimated_amount": 205514.19, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Senior HMO", "standard_charge_percentage": 100, "estimated_amount": 178707.99, "methodology": "fee schedule" }, { "payer_name": "Alignment", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 178707.99, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 178707.99, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Duals", "standard_charge_percentage": 100, "estimated_amount": 178707.99, "methodology": "fee schedule" }, { "payer_name": "Pipeline formerly Avanti", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 178707.99, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 178707.99, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 178707.99, "methodology": "fee schedule" }, { "payer_name": "Imperial Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 178707.99, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 178707.99, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "C-SNP (Chronic Special Needs Plan)", "standard_charge_percentage": 100, "estimated_amount": 178707.99, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN Network", "standard_charge_percentage": 100, "estimated_amount": 186736.59, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 178707.99, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Special Needs Plan (SNP)", "standard_charge_percentage": 100, "estimated_amount": 178707.99, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Medicare Advantage Prescription Drug (MAPD)", "standard_charge_percentage": 100, "estimated_amount": 178707.99, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 178707.99, "methodology": "fee schedule" }, { "payer_name": "Access Senior Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 178707.99, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 178707.99, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 214653.24, "methodology": "fee schedule" }, { "payer_name": "AltaMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 178707.99, "methodology": "fee schedule" }, { "payer_name": "Clever Care Health", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "estimated_amount": 178707.99, "methodology": "fee schedule" }, { "payer_name": "Anthem", "plan_name": "Medicare Advantage", "standard_charge_percentage": 106, "estimated_amount": 189430.47, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 178707.99, "methodology": "fee schedule" }, { "payer_name": "California State Prison", "plan_name": "Prison Healthcare Provider Network Project", "standard_charge_percentage": 125, "estimated_amount": 223384.99, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 178707.99, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Commercial", "standard_charge_percentage": 130, "estimated_amount": 232320.39, "methodology": "fee schedule" }, { "payer_name": "Medicare", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 178707.99, "methodology": "fee schedule" }, { "payer_name": "K-Day", "plan_name": "PACE", "standard_charge_percentage": 100, "estimated_amount": 178707.99, "methodology": "fee schedule" } ], "minimum": 178707.99, "maximum": 232320.39 } ] }, { "description": "Tracheostomy with MV >96 Hours or Principal Diagnosis Except Face, Mouth and Neck without Major O.R. Procedures", "code_information": [ { "code": "004", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Alta Hospital Systems", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 123216.25, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "HMO", "standard_charge_percentage": 120, "estimated_amount": 147859.5, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 123216.25, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 123216.25, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "DSNP", "standard_charge_percentage": 100, "estimated_amount": 123216.25, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Self-Funded EPO/PPO", "standard_charge_percentage": 120, "estimated_amount": 147859.5, "methodology": "fee schedule" }, { "payer_name": "New Century Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 123216.25, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "L.A. Care Covered California", "standard_charge_percentage": 114.99999999999999, "estimated_amount": 141698.69, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Senior HMO", "standard_charge_percentage": 100, "estimated_amount": 123216.25, "methodology": "fee schedule" }, { "payer_name": "Alignment", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 123216.25, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 123216.25, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Duals", "standard_charge_percentage": 100, "estimated_amount": 123216.25, "methodology": "fee schedule" }, { "payer_name": "Pipeline formerly Avanti", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 123216.25, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 123216.25, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 123216.25, "methodology": "fee schedule" }, { "payer_name": "Imperial Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 123216.25, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 123216.25, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "C-SNP (Chronic Special Needs Plan)", "standard_charge_percentage": 100, "estimated_amount": 123216.25, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN Network", "standard_charge_percentage": 100, "estimated_amount": 123385.17, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 123216.25, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Special Needs Plan (SNP)", "standard_charge_percentage": 100, "estimated_amount": 123216.25, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Medicare Advantage Prescription Drug (MAPD)", "standard_charge_percentage": 100, "estimated_amount": 123216.25, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 123216.25, "methodology": "fee schedule" }, { "payer_name": "Access Senior Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 123216.25, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 123216.25, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 141830.95, "methodology": "fee schedule" }, { "payer_name": "AltaMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 123216.25, "methodology": "fee schedule" }, { "payer_name": "Clever Care Health", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "estimated_amount": 123216.25, "methodology": "fee schedule" }, { "payer_name": "Anthem", "plan_name": "Medicare Advantage", "standard_charge_percentage": 106, "estimated_amount": 130609.23, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 123216.25, "methodology": "fee schedule" }, { "payer_name": "California State Prison", "plan_name": "Prison Healthcare Provider Network Project", "standard_charge_percentage": 125, "estimated_amount": 154020.31, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 123216.25, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Commercial", "standard_charge_percentage": 130, "estimated_amount": 160181.13, "methodology": "fee schedule" }, { "payer_name": "Medicare", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 123216.25, "methodology": "fee schedule" }, { "payer_name": "K-Day", "plan_name": "PACE", "standard_charge_percentage": 100, "estimated_amount": 123216.25, "methodology": "fee schedule" } ], "minimum": 123216.25, "maximum": 160181.13 } ] }, { "description": "Liver Transplant with MCC or Intestinal Transplant", "code_information": [ { "code": "005", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Alta Hospital Systems", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 87699.59, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "HMO", "standard_charge_percentage": 120, "estimated_amount": 105239.51, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 87699.59, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 87699.59, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "DSNP", "standard_charge_percentage": 100, "estimated_amount": 87699.59, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Self-Funded EPO/PPO", "standard_charge_percentage": 120, "estimated_amount": 105239.51, "methodology": "fee schedule" 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"plan_name": "Prison Healthcare Provider Network Project", "standard_charge_percentage": 125, "estimated_amount": 18746.48, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 14997.18, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Commercial", "standard_charge_percentage": 130, "estimated_amount": 19496.33, "methodology": "fee schedule" }, { "payer_name": "Medicare", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 14997.18, "methodology": "fee schedule" }, { "payer_name": "K-Day", "plan_name": "PACE", "standard_charge_percentage": 100, "estimated_amount": 14997.18, "methodology": "fee schedule" } ], "minimum": 14997.18, "maximum": 19496.33 } ] }, { "description": "Other Disorders of Nervous System with CC", "code_information": [ { "code": "092", "type": "MS-DRG" } ], "standard_charges": 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California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 13847.16, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 13847.16, "methodology": "fee schedule" }, { "payer_name": "Imperial Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 13847.16, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 13847.16, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "C-SNP (Chronic Special Needs Plan)", "standard_charge_percentage": 100, "estimated_amount": 13847.16, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN Network", "standard_charge_percentage": 100, "estimated_amount": 14592.75, "methodology": "fee schedule" 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"plan_name": "Prison Healthcare Provider Network Project", "standard_charge_percentage": 125, "estimated_amount": 17308.95, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 13847.16, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Commercial", "standard_charge_percentage": 130, "estimated_amount": 18001.31, "methodology": "fee schedule" }, { "payer_name": "Medicare", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 13847.16, "methodology": "fee schedule" }, { "payer_name": "K-Day", "plan_name": "PACE", "standard_charge_percentage": 100, "estimated_amount": 13847.16, "methodology": "fee schedule" } ], "minimum": 13847.16, "maximum": 18001.31 } ] }, { "description": "Major Esophageal Disorders with CC", "code_information": [ { "code": "369", "type": "MS-DRG" } ], "standard_charges": [ { 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"plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 8342.6, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 8342.6, "methodology": "fee schedule" }, { "payer_name": "Imperial Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 8342.6, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 8342.6, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "C-SNP (Chronic Special Needs Plan)", "standard_charge_percentage": 100, "estimated_amount": 8342.6, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN Network", "standard_charge_percentage": 100, "estimated_amount": 8857.57, "methodology": "fee schedule" }, { "payer_name": "LA 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Healthcare Provider Network Project", "standard_charge_percentage": 125, "estimated_amount": 10428.25, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 8342.6, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Commercial", "standard_charge_percentage": 130, "estimated_amount": 10845.38, "methodology": "fee schedule" }, { "payer_name": "Medicare", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 8342.6, "methodology": "fee schedule" }, { "payer_name": "K-Day", "plan_name": "PACE", "standard_charge_percentage": 100, "estimated_amount": 8342.6, "methodology": "fee schedule" } ], "minimum": 8342.6, "maximum": 10845.38 } ] }, { "description": "Major Esophageal Disorders without CC/MCC", "code_information": [ { "code": "370", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Alta Hospital Systems", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 6233.74, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "HMO", "standard_charge_percentage": 120, "estimated_amount": 7480.49, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 6233.74, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 6233.74, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "DSNP", "standard_charge_percentage": 100, "estimated_amount": 6233.74, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Self-Funded EPO/PPO", "standard_charge_percentage": 120, "estimated_amount": 7480.49, "methodology": "fee schedule" }, { "payer_name": "New Century Health Plan", "plan_name": 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Care Covered California", "standard_charge_percentage": 114.99999999999999, "estimated_amount": 7168.8, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Senior HMO", "standard_charge_percentage": 100, "estimated_amount": 6233.74, "methodology": "fee schedule" }, { "payer_name": "Alignment", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 6233.74, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 6233.74, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Duals", "standard_charge_percentage": 100, "estimated_amount": 6233.74, "methodology": "fee schedule" }, { "payer_name": "Pipeline formerly Avanti", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 6233.74, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 6233.74, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 6233.74, "methodology": "fee schedule" }, { "payer_name": "Imperial Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 6233.74, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 6233.74, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "C-SNP (Chronic Special Needs Plan)", "standard_charge_percentage": 100, "estimated_amount": 6233.74, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN Network", "standard_charge_percentage": 100, "estimated_amount": 6061.78, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 6233.74, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Special Needs Plan (SNP)", "standard_charge_percentage": 100, "estimated_amount": 6233.74, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Medicare Advantage Prescription Drug (MAPD)", "standard_charge_percentage": 100, "estimated_amount": 6233.74, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 6233.74, "methodology": "fee schedule" }, { "payer_name": "Access Senior Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 6233.74, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 6233.74, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 6968, "methodology": "fee schedule" }, { "payer_name": "AltaMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 6233.74, "methodology": "fee schedule" }, { "payer_name": "Clever Care Health", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "estimated_amount": 6233.74, "methodology": "fee schedule" }, { "payer_name": "Anthem", "plan_name": "Medicare Advantage", "standard_charge_percentage": 106, "estimated_amount": 6607.76, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 6233.74, "methodology": "fee schedule" }, { "payer_name": "California State Prison", "plan_name": "Prison Healthcare Provider Network Project", "standard_charge_percentage": 125, "estimated_amount": 7792.18, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 6233.74, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Commercial", "standard_charge_percentage": 130, "estimated_amount": 8103.86, "methodology": "fee schedule" }, { "payer_name": "Medicare", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 6233.74, "methodology": "fee schedule" }, { "payer_name": "K-Day", "plan_name": "PACE", "standard_charge_percentage": 100, "estimated_amount": 6233.74, "methodology": "fee schedule" } ], "minimum": 6061.78, "maximum": 8103.86 } ] }, { "description": "Major Gastrointestinal Disorders and Peritoneal Infections with MCC", "code_information": [ { "code": "371", "type": "MS-DRG" } ], "standard_charges": [ 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Care Covered California", "standard_charge_percentage": 114.99999999999999, "estimated_amount": 9031.12, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Senior HMO", "standard_charge_percentage": 100, "estimated_amount": 7853.15, "methodology": "fee schedule" }, { "payer_name": "Alignment", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 7853.15, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 7853.15, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Duals", "standard_charge_percentage": 100, "estimated_amount": 7853.15, "methodology": "fee schedule" }, { "payer_name": "Pipeline formerly Avanti", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 7853.15, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 7853.15, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 7853.15, "methodology": "fee schedule" }, { "payer_name": "Imperial Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 7853.15, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 7853.15, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "C-SNP (Chronic Special Needs Plan)", "standard_charge_percentage": 100, "estimated_amount": 7853.15, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN Network", "standard_charge_percentage": 100, "estimated_amount": 8196.49, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 7853.15, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Special Needs Plan (SNP)", "standard_charge_percentage": 100, "estimated_amount": 7853.15, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Medicare Advantage Prescription Drug (MAPD)", "standard_charge_percentage": 100, "estimated_amount": 7853.15, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 7853.15, "methodology": "fee schedule" }, { "payer_name": "Access Senior Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 7853.15, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 7853.15, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 9421.85, "methodology": "fee schedule" }, { "payer_name": "AltaMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 7853.15, "methodology": "fee schedule" }, { "payer_name": "Clever Care Health", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "estimated_amount": 7853.15, "methodology": "fee schedule" }, { "payer_name": "Anthem", "plan_name": "Medicare Advantage", "standard_charge_percentage": 106, "estimated_amount": 8324.34, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 7853.15, "methodology": "fee schedule" }, { "payer_name": "California State Prison", "plan_name": "Prison Healthcare Provider Network Project", "standard_charge_percentage": 125, "estimated_amount": 9816.44, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 7853.15, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Commercial", "standard_charge_percentage": 130, "estimated_amount": 10209.1, "methodology": "fee schedule" }, { "payer_name": "Medicare", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 7853.15, "methodology": "fee schedule" }, { "payer_name": "K-Day", "plan_name": "PACE", "standard_charge_percentage": 100, "estimated_amount": 7853.15, "methodology": "fee schedule" } ], "minimum": 7853.15, "maximum": 10209.1 } ] }, { "description": "Other Digestive System Diagnoses without CC/MCC", "code_information": [ { "code": "395", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Alta Hospital Systems", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 5427.38, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "HMO", "standard_charge_percentage": 120, "estimated_amount": 6512.86, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 5427.38, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 5427.38, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "DSNP", "standard_charge_percentage": 100, "estimated_amount": 5427.38, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Self-Funded EPO/PPO", "standard_charge_percentage": 120, "estimated_amount": 6512.86, "methodology": "fee schedule" }, { "payer_name": "New Century Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 5427.38, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "L.A. Care Covered California", "standard_charge_percentage": 114.99999999999999, "estimated_amount": 6241.49, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Senior HMO", "standard_charge_percentage": 100, "estimated_amount": 5427.38, "methodology": "fee schedule" }, { "payer_name": "Alignment", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 5427.38, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 5427.38, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Duals", "standard_charge_percentage": 100, "estimated_amount": 5427.38, "methodology": "fee schedule" }, { "payer_name": "Pipeline formerly Avanti", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 5427.38, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 5427.38, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 5427.38, "methodology": "fee schedule" }, { "payer_name": "Imperial Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 5427.38, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 5427.38, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "C-SNP (Chronic Special Needs Plan)", "standard_charge_percentage": 100, "estimated_amount": 5427.38, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN Network", "standard_charge_percentage": 100, "estimated_amount": 5544.3, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 5427.38, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Special Needs Plan (SNP)", "standard_charge_percentage": 100, "estimated_amount": 5427.38, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Medicare Advantage Prescription Drug (MAPD)", "standard_charge_percentage": 100, "estimated_amount": 5427.38, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 5427.38, "methodology": "fee schedule" }, { "payer_name": "Access Senior Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 5427.38, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 5427.38, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 6373.16, "methodology": "fee schedule" }, { "payer_name": "AltaMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 5427.38, "methodology": "fee schedule" }, { "payer_name": "Clever Care Health", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "estimated_amount": 5427.38, "methodology": "fee schedule" }, { "payer_name": "Anthem", "plan_name": "Medicare Advantage", "standard_charge_percentage": 106, "estimated_amount": 5753.02, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 5427.38, "methodology": "fee schedule" }, { "payer_name": "California State Prison", "plan_name": "Prison Healthcare Provider Network Project", "standard_charge_percentage": 125, "estimated_amount": 6784.23, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 5427.38, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Commercial", "standard_charge_percentage": 130, "estimated_amount": 7055.59, "methodology": "fee schedule" }, { "payer_name": "Medicare", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 5427.38, "methodology": "fee schedule" }, { "payer_name": "K-Day", "plan_name": "PACE", "standard_charge_percentage": 100, "estimated_amount": 5427.38, "methodology": "fee schedule" } ], "minimum": 5427.38, "maximum": 7055.59 } ] }, { "description": "Appendix Procedures with MCC", "code_information": [ { "code": "397", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Alta Hospital Systems", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 20443.34, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "HMO", "standard_charge_percentage": 120, "estimated_amount": 24532.01, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 20443.34, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 20443.34, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "DSNP", "standard_charge_percentage": 100, "estimated_amount": 20443.34, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Self-Funded EPO/PPO", "standard_charge_percentage": 120, "estimated_amount": 24532.01, "methodology": "fee schedule" }, { "payer_name": "New Century Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 20443.34, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "L.A. Care Covered California", "standard_charge_percentage": 114.99999999999999, "estimated_amount": 23509.84, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Senior HMO", "standard_charge_percentage": 100, "estimated_amount": 20443.34, "methodology": "fee schedule" }, { "payer_name": "Alignment", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 20443.34, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 20443.34, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Duals", "standard_charge_percentage": 100, "estimated_amount": 20443.34, "methodology": "fee schedule" }, { "payer_name": "Pipeline formerly Avanti", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 20443.34, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 20443.34, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 20443.34, "methodology": "fee schedule" }, { "payer_name": "Imperial Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 20443.34, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 20443.34, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "C-SNP (Chronic Special Needs Plan)", "standard_charge_percentage": 100, "estimated_amount": 20443.34, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN Network", "standard_charge_percentage": 100, "estimated_amount": 21705.25, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 20443.34, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Special Needs Plan (SNP)", "standard_charge_percentage": 100, "estimated_amount": 20443.34, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Medicare Advantage Prescription Drug (MAPD)", "standard_charge_percentage": 100, "estimated_amount": 20443.34, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 20443.34, "methodology": "fee schedule" }, { "payer_name": "Access Senior Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 20443.34, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 20443.34, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 24950.13, "methodology": "fee schedule" }, { "payer_name": "AltaMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 20443.34, "methodology": "fee schedule" }, { "payer_name": "Clever Care Health", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "estimated_amount": 20443.34, "methodology": "fee schedule" }, { "payer_name": "Anthem", "plan_name": "Medicare Advantage", "standard_charge_percentage": 106, "estimated_amount": 21669.94, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 20443.34, "methodology": "fee schedule" }, { "payer_name": "California State Prison", "plan_name": "Prison Healthcare Provider Network Project", "standard_charge_percentage": 125, "estimated_amount": 25554.18, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 20443.34, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Commercial", "standard_charge_percentage": 130, "estimated_amount": 26576.34, "methodology": "fee schedule" }, { "payer_name": "Medicare", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 20443.34, "methodology": "fee schedule" }, { "payer_name": "K-Day", "plan_name": "PACE", "standard_charge_percentage": 100, "estimated_amount": 20443.34, "methodology": "fee schedule" } ], "minimum": 20443.34, "maximum": 26576.34 } ] }, { "description": "Appendix Procedures with CC", "code_information": [ { "code": "398", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Alta Hospital Systems", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 12684.57, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "HMO", "standard_charge_percentage": 120, "estimated_amount": 15221.48, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 12684.57, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 12684.57, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "DSNP", "standard_charge_percentage": 100, "estimated_amount": 12684.57, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Self-Funded EPO/PPO", "standard_charge_percentage": 120, "estimated_amount": 15221.48, "methodology": "fee schedule" }, { "payer_name": "New Century Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 12684.57, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "L.A. Care Covered California", "standard_charge_percentage": 114.99999999999999, "estimated_amount": 14587.26, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Senior HMO", "standard_charge_percentage": 100, "estimated_amount": 12684.57, "methodology": "fee schedule" }, { "payer_name": "Alignment", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 12684.57, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 12684.57, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Duals", "standard_charge_percentage": 100, "estimated_amount": 12684.57, "methodology": "fee schedule" }, { "payer_name": "Pipeline formerly Avanti", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 12684.57, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 12684.57, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 12684.57, "methodology": "fee schedule" }, { "payer_name": "Imperial Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 12684.57, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 12684.57, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "C-SNP (Chronic Special Needs Plan)", "standard_charge_percentage": 100, "estimated_amount": 12684.57, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN Network", "standard_charge_percentage": 100, "estimated_amount": 13219.81, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 12684.57, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Special Needs Plan (SNP)", "standard_charge_percentage": 100, "estimated_amount": 12684.57, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Medicare Advantage Prescription Drug (MAPD)", "standard_charge_percentage": 100, "estimated_amount": 12684.57, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 12684.57, "methodology": "fee schedule" }, { "payer_name": "Access Senior Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 12684.57, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Medicare 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"plan_name": "Prison Healthcare Provider Network Project", "standard_charge_percentage": 125, "estimated_amount": 15855.71, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 12684.57, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Commercial", "standard_charge_percentage": 130, "estimated_amount": 16489.94, "methodology": "fee schedule" }, { "payer_name": "Medicare", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 12684.57, "methodology": "fee schedule" }, { "payer_name": "K-Day", "plan_name": "PACE", "standard_charge_percentage": 100, "estimated_amount": 12684.57, "methodology": "fee schedule" } ], "minimum": 12684.57, "maximum": 16489.94 } ] }, { "description": "Appendix Procedures without CC/MCC", "code_information": [ { "code": "399", "type": "MS-DRG" } ], "standard_charges": [ { 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"Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 12186, "methodology": "case rate" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 10844, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 90272, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 90272, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 90272, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 90272, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 90272, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 90272, "methodology": "case rate" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 12186, "methodology": "case rate" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 11563, "methodology": "case rate" } ], "minimum": 10844, "maximum": 90272 } ] }, { "description": "Cardiac pacemaker implant without MCC.", "code_information": [ { "code": "227", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 12186, "methodology": "case rate" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 10844, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 67197, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 67197, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 67197, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 67197, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 67197, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 67197, "methodology": "case rate" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 12186, "methodology": "case rate" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 11563, "methodology": "case rate" } ], "minimum": 10844, "maximum": 67197 } ] }, { "description": "Other Cardiothoracic Procedures with MCC", "code_information": [ { "code": "228", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Alta Hospital Systems", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 42234.68, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "HMO", "standard_charge_percentage": 120, "estimated_amount": 50681.62, "methodology": "fee schedule" }, { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 28483, "methodology": "case rate" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 25800, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 42234.68, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 42234.68, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "DSNP", "standard_charge_percentage": 100, "estimated_amount": 42234.68, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Self-Funded EPO/PPO", "standard_charge_percentage": 120, "estimated_amount": 50681.62, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 104724, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 104724, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 104724, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 104724, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 104724, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 104724, "methodology": "case rate" }, { "payer_name": "New Century Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 42234.68, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "L.A. Care Covered California", "standard_charge_percentage": 114.99999999999999, "estimated_amount": 48569.88, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Senior HMO", "standard_charge_percentage": 100, "estimated_amount": 42234.68, "methodology": "fee schedule" }, { "payer_name": "Alignment", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 42234.68, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 42234.68, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Duals", "standard_charge_percentage": 100, "estimated_amount": 42234.68, "methodology": "fee schedule" }, { "payer_name": "Pipeline formerly Avanti", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 42234.68, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 42234.68, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 42234.68, "methodology": "fee schedule" }, { "payer_name": "Imperial Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 42234.68, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 42234.68, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "C-SNP (Chronic Special Needs Plan)", "standard_charge_percentage": 100, "estimated_amount": 42234.68, "methodology": "fee schedule" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 28483, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN Network", "standard_charge_percentage": 100, "estimated_amount": 43998.9, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 42234.68, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Special Needs Plan (SNP)", "standard_charge_percentage": 100, "estimated_amount": 42234.68, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Medicare Advantage Prescription Drug (MAPD)", "standard_charge_percentage": 100, "estimated_amount": 42234.68, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 27508, "methodology": "case rate" }, { "payer_name": "Brand New Day", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 42234.68, "methodology": "fee schedule" }, { "payer_name": "Access Senior Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 42234.68, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 42234.68, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 50576.63, "methodology": "fee schedule" }, { "payer_name": "AltaMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 42234.68, "methodology": "fee schedule" }, { "payer_name": "Clever Care Health", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "estimated_amount": 42234.68, "methodology": "fee schedule" }, { "payer_name": "Anthem", "plan_name": "Medicare Advantage", "standard_charge_percentage": 106, "estimated_amount": 44768.76, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 42234.68, "methodology": "fee schedule" }, { "payer_name": "California State Prison", "plan_name": "Prison Healthcare Provider Network Project", "standard_charge_percentage": 125, "estimated_amount": 52793.35, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 42234.68, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Commercial", "standard_charge_percentage": 130, "estimated_amount": 54905.08, "methodology": "fee schedule" }, { "payer_name": "Medicare", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 42234.68, "methodology": "fee schedule" }, { "payer_name": "K-Day", "plan_name": "PACE", "standard_charge_percentage": 100, "estimated_amount": 42234.68, "methodology": "fee schedule" } ], "minimum": 25800, "maximum": 104724 } ] }, { "description": "Other Cardiothoracic Procedures without MCC", "code_information": [ { "code": "229", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Alta Hospital Systems", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 26651.59, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "HMO", "standard_charge_percentage": 120, "estimated_amount": 31981.91, "methodology": "fee schedule" }, { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 28483, "methodology": "case rate" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 25800, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 26651.59, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 26651.59, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "DSNP", "standard_charge_percentage": 100, "estimated_amount": 26651.59, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Self-Funded EPO/PPO", "standard_charge_percentage": 120, "estimated_amount": 31981.91, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 67535, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 67535, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 67535, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 67535, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 67535, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 67535, "methodology": "case rate" }, { "payer_name": "New Century Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 26651.59, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "L.A. Care Covered California", "standard_charge_percentage": 114.99999999999999, "estimated_amount": 30649.33, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Senior HMO", "standard_charge_percentage": 100, "estimated_amount": 26651.59, "methodology": "fee schedule" }, { "payer_name": "Alignment", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 26651.59, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 26651.59, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Duals", "standard_charge_percentage": 100, "estimated_amount": 26651.59, "methodology": "fee schedule" }, { "payer_name": "Pipeline formerly Avanti", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 26651.59, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 26651.59, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 26651.59, "methodology": "fee schedule" }, { "payer_name": "Imperial Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 26651.59, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 26651.59, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "C-SNP (Chronic Special Needs Plan)", "standard_charge_percentage": 100, "estimated_amount": 26651.59, "methodology": "fee schedule" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 28483, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN Network", "standard_charge_percentage": 100, "estimated_amount": 27487.71, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 26651.59, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Special Needs Plan (SNP)", "standard_charge_percentage": 100, "estimated_amount": 26651.59, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Medicare Advantage Prescription Drug (MAPD)", "standard_charge_percentage": 100, "estimated_amount": 26651.59, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 27508, "methodology": "case rate" }, { "payer_name": "Brand New Day", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 26651.59, "methodology": "fee schedule" }, { "payer_name": "Access Senior Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 26651.59, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 26651.59, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 31597.05, "methodology": "fee schedule" }, { "payer_name": "AltaMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 26651.59, "methodology": "fee schedule" }, { "payer_name": "Clever Care Health", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "estimated_amount": 26651.59, "methodology": "fee schedule" }, { "payer_name": "Anthem", "plan_name": "Medicare Advantage", "standard_charge_percentage": 106, "estimated_amount": 28250.69, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 26651.59, "methodology": "fee schedule" }, { "payer_name": "California State Prison", "plan_name": "Prison Healthcare Provider Network Project", "standard_charge_percentage": 125, "estimated_amount": 33314.49, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 26651.59, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Commercial", "standard_charge_percentage": 130, "estimated_amount": 34647.07, "methodology": "fee schedule" }, { "payer_name": "Medicare", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 26651.59, "methodology": "fee schedule" }, { "payer_name": "K-Day", "plan_name": "PACE", "standard_charge_percentage": 100, "estimated_amount": 26651.59, "methodology": "fee schedule" } ], "minimum": 25800, "maximum": 67535 } ] }, { "description": "Hip & femur procedures except major joint with MCC.", "code_information": [ { "code": "230", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 28483, "methodology": "case rate" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 25800, "methodology": "case rate" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 28483, "methodology": "case rate" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 27508, "methodology": "case rate" } ], "minimum": 25800, "maximum": 28483 } ] }, { "description": "Coronary Bypass with PTCA with MCC", "code_information": [ { "code": "231", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Alta Hospital Systems", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 70291.13, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "HMO", "standard_charge_percentage": 120, "estimated_amount": 84349.36, "methodology": "fee schedule" }, { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 28483, "methodology": "case rate" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 25800, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 70291.13, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 70291.13, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 30394, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "Open Access", "standard_charge_dollar": 30394, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "Network", "standard_charge_dollar": 30394, "methodology": "case rate" }, { "payer_name": "Cigna", "plan_name": "HMO", "standard_charge_dollar": 30394, "methodology": "case rate" }, { "payer_name": "LA Care", "plan_name": "DSNP", "standard_charge_percentage": 100, "estimated_amount": 70291.13, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Self-Funded EPO/PPO", "standard_charge_percentage": 120, "estimated_amount": 84349.36, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 102807, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 102807, "methodology": "case 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"estimated_amount": 40480.1, "methodology": "fee schedule" }, { "payer_name": "California State Prison", "plan_name": "Prison Healthcare Provider Network Project", "standard_charge_percentage": 125, "estimated_amount": 50600.13, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 40480.1, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Commercial", "standard_charge_percentage": 130, "estimated_amount": 52624.13, "methodology": "fee schedule" }, { "payer_name": "Medicare", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 40480.1, "methodology": "fee schedule" }, { "payer_name": "K-Day", "plan_name": "PACE", "standard_charge_percentage": 100, "estimated_amount": 40480.1, "methodology": "fee schedule" } ], "minimum": 12186, "maximum": 52624.13 } ] }, { "description": "Percutaneous cardiovascular procedure with drug-eluting stent without MCC.", "code_information": [ { "code": "246", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 9257, "methodology": "case rate" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 4449, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 4449, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 4449, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 4449, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 7875, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 7875, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 7875, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 7875, "methodology": "case rate" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 6065, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 42324, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 42324, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 42324, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 42324, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 42324, "methodology": "case rate" }, { "payer_name": "Kaiser", "plan_name": "Commercial", "standard_charge_dollar": 26000, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 42324, "methodology": "case rate" }, { "payer_name": "Kaiser", "plan_name": "Medi-Cal", "standard_charge_dollar": 26000, "methodology": "case rate" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 9257, "methodology": "case rate" }, { "payer_name": "Kaiser", "plan_name": "Medicare", "standard_charge_dollar": 26000, "methodology": "case rate" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 6467, "methodology": "case rate" } ], "minimum": 4449, "maximum": 42324 } ] }, { "description": "Percutaneous cardiovascular procedure without coronary-artery stent with MCC.", "code_information": [ { "code": "247", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 9257, "methodology": "case rate" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 4449, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 4449, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 4449, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 4449, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 7875, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 7875, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 7875, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 7875, "methodology": "case rate" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 6065, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 25725, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 25725, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 25725, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 25725, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 25725, "methodology": "case rate" }, { "payer_name": "Kaiser", "plan_name": "Commercial", "standard_charge_dollar": 26000, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 25725, "methodology": "case rate" }, { "payer_name": "Kaiser", "plan_name": "Medi-Cal", "standard_charge_dollar": 26000, "methodology": "case rate" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 9257, "methodology": "case rate" }, { "payer_name": "Kaiser", "plan_name": "Medicare", "standard_charge_dollar": 26000, "methodology": "case rate" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 6467, "methodology": "case rate" } ], "minimum": 4449, "maximum": 26000 } ] }, { "description": "Percutaneous cardiovascular procedure without coronary-artery stent without MCC.", "code_information": [ { "code": "248", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 9257, "methodology": "case rate" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 4449, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 4449, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 4449, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 4449, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 7875, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 7875, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 7875, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 7875, "methodology": "case rate" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 6065, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 37720, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 37720, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 37720, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 37720, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 37720, "methodology": "case rate" }, { "payer_name": "Kaiser", "plan_name": "Commercial", "standard_charge_dollar": 26000, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 37720, "methodology": "case rate" }, { "payer_name": "Kaiser", "plan_name": "Medi-Cal", "standard_charge_dollar": 26000, "methodology": "case rate" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 9257, "methodology": "case rate" }, { "payer_name": "Kaiser", "plan_name": "Medicare", "standard_charge_dollar": 26000, "methodology": "case rate" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 6467, "methodology": "case rate" } ], "minimum": 4449, "maximum": 37720 } ] }, { "description": "Percutaneous cardiovascular procedure with non-drug-eluting stent without MCC.", "code_information": [ { "code": "249", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 9257, "methodology": "case rate" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 4449, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 4449, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 4449, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 4449, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 7875, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 7875, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 7875, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 7875, "methodology": "case rate" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 6065, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 23815, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 23815, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 23815, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 23815, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 23815, "methodology": "case rate" }, { "payer_name": "Kaiser", "plan_name": "Commercial", "standard_charge_dollar": 26000, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 23815, "methodology": "case rate" }, { "payer_name": "Kaiser", "plan_name": "Medi-Cal", "standard_charge_dollar": 26000, "methodology": "case rate" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 9257, "methodology": "case rate" }, { "payer_name": "Kaiser", "plan_name": "Medicare", "standard_charge_dollar": 26000, "methodology": "case rate" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 6467, "methodology": "case rate" } ], "minimum": 4449, "maximum": 26000 } ] }, { "description": "Percutaneous Cardiovascular Procedures without Intraluminal Device with MCC", "code_information": [ { "code": "250", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Alta Hospital Systems", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 19704.54, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "HMO", "standard_charge_percentage": 120, "estimated_amount": 23645.45, "methodology": "fee schedule" }, { "payer_name": "Optum", "plan_name": "Commercial HMO/POS", "standard_charge_dollar": 9257, "methodology": "case rate" }, { "payer_name": "Anthem", "plan_name": "All Other Commercial Products", "standard_charge_dollar": 4449, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "Indemnity", "standard_charge_dollar": 4449, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "PPO", "standard_charge_dollar": 4449, "methodology": "per diem" }, { "payer_name": "Anthem", "plan_name": "HMO", "standard_charge_dollar": 4449, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "EPO", "standard_charge_dollar": 7875, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "PPO", "standard_charge_dollar": 7875, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "HMO", "standard_charge_dollar": 7875, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "POS", "standard_charge_dollar": 7875, "methodology": "case rate" }, { "payer_name": "Health Net of California", "plan_name": "Tailored Network", "standard_charge_dollar": 6065, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 19704.54, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 19704.54, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "DSNP", "standard_charge_percentage": 100, "estimated_amount": 19704.54, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Self-Funded EPO/PPO", "standard_charge_percentage": 120, "estimated_amount": 23645.45, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select Plus", "standard_charge_dollar": 40235, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Select", "standard_charge_dollar": 40235, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Navigate", "standard_charge_dollar": 40235, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Core", "standard_charge_dollar": 40235, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "HMO", "standard_charge_dollar": 40235, "methodology": "case rate" }, { "payer_name": "Kaiser", "plan_name": "Commercial", "standard_charge_dollar": 26000, "methodology": "case rate" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Commercial - All Payer", "standard_charge_dollar": 40235, "methodology": "case rate" }, { "payer_name": "New Century Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 19704.54, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "L.A. Care Covered California", "standard_charge_percentage": 114.99999999999999, "estimated_amount": 22660.22, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Senior HMO", "standard_charge_percentage": 100, "estimated_amount": 19704.54, "methodology": "fee schedule" }, { "payer_name": "Alignment", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 19704.54, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 19704.54, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Duals", "standard_charge_percentage": 100, "estimated_amount": 19704.54, "methodology": "fee schedule" }, { "payer_name": "Pipeline formerly Avanti", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 19704.54, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 19704.54, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 19704.54, "methodology": "fee schedule" }, { "payer_name": "Imperial Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 19704.54, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 19704.54, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "C-SNP (Chronic Special Needs Plan)", "standard_charge_percentage": 100, "estimated_amount": 19704.54, "methodology": "fee schedule" }, { "payer_name": "Kaiser", "plan_name": "Medi-Cal", "standard_charge_dollar": 26000, "methodology": "case rate" }, { "payer_name": "Optum", "plan_name": "Medicare Advantage", "standard_charge_dollar": 9257, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN Network", "standard_charge_percentage": 100, "estimated_amount": 20271.02, "methodology": "fee schedule" }, { "payer_name": "Kaiser", "plan_name": "Medicare", "standard_charge_dollar": 26000, "methodology": "case rate" }, { "payer_name": "LA Care", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 19704.54, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Special Needs Plan (SNP)", "standard_charge_percentage": 100, "estimated_amount": 19704.54, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Medicare Advantage Prescription Drug (MAPD)", "standard_charge_percentage": 100, "estimated_amount": 19704.54, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Commercial", "standard_charge_dollar": 6467, "methodology": "case rate" }, { "payer_name": "Brand New Day", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 19704.54, "methodology": "fee schedule" }, { "payer_name": "Access Senior Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 19704.54, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 19704.54, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 23301.48, "methodology": "fee schedule" }, { "payer_name": "AltaMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 19704.54, "methodology": "fee schedule" }, { "payer_name": "Clever Care Health", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "estimated_amount": 19704.54, "methodology": "fee schedule" }, { "payer_name": "Anthem", "plan_name": "Medicare Advantage", "standard_charge_percentage": 106, "estimated_amount": 20886.81, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 19704.54, "methodology": "fee schedule" }, { "payer_name": "California State Prison", "plan_name": "Prison Healthcare Provider Network Project", "standard_charge_percentage": 125, "estimated_amount": 24630.68, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 19704.54, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Commercial", "standard_charge_percentage": 130, "estimated_amount": 25615.9, "methodology": "fee 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}, { "payer_name": "LA Care", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 19232.69, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Special Needs Plan (SNP)", "standard_charge_percentage": 100, "estimated_amount": 19232.69, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Medicare Advantage Prescription Drug (MAPD)", "standard_charge_percentage": 100, "estimated_amount": 19232.69, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 19232.69, "methodology": "fee schedule" }, { "payer_name": "Access Senior Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 19232.69, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Medicare 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Healthcare Provider Network Project", "standard_charge_percentage": 125, "estimated_amount": 8397.78, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 6718.22, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Commercial", "standard_charge_percentage": 130, "estimated_amount": 8733.69, "methodology": "fee schedule" }, { "payer_name": "Medicare", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 6718.22, "methodology": "fee schedule" }, { "payer_name": "K-Day", "plan_name": "PACE", "standard_charge_percentage": 100, "estimated_amount": 6718.22, "methodology": "fee schedule" } ], "minimum": 6718.22, "maximum": 8733.69 } ] }, { "description": "Multiple Level Spinal Fusion Except Cervical with MCC or Custom-Made Anatomically Designed Interbody Fusion Device", "code_information": [ { "code": "447", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Alta Hospital Systems", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 55547.25, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "HMO", "standard_charge_percentage": 120, "estimated_amount": 66656.7, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 55547.25, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 55547.25, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "DSNP", "standard_charge_percentage": 100, "estimated_amount": 55547.25, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Self-Funded EPO/PPO", "standard_charge_percentage": 120, "estimated_amount": 66656.7, 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California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 55547.25, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 55547.25, "methodology": "fee schedule" }, { "payer_name": "Imperial Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 55547.25, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 55547.25, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "C-SNP (Chronic Special Needs Plan)", "standard_charge_percentage": 100, "estimated_amount": 55547.25, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN Network", "standard_charge_percentage": 100, "estimated_amount": 58976.04, "methodology": "fee schedule" 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Advantage", "standard_charge_percentage": 100, "estimated_amount": 55547.25, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 67792.81, "methodology": "fee schedule" }, { "payer_name": "AltaMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 55547.25, "methodology": "fee schedule" }, { "payer_name": "Clever Care Health", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "estimated_amount": 55547.25, "methodology": "fee schedule" }, { "payer_name": "Anthem", "plan_name": "Medicare Advantage", "standard_charge_percentage": 106, "estimated_amount": 58880.09, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 55547.25, "methodology": "fee schedule" }, { "payer_name": "California State Prison", "plan_name": "Prison Healthcare Provider Network Project", "standard_charge_percentage": 125, "estimated_amount": 69434.06, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 55547.25, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Commercial", "standard_charge_percentage": 130, "estimated_amount": 72211.43, "methodology": "fee schedule" }, { "payer_name": "Medicare", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 55547.25, "methodology": "fee schedule" }, { "payer_name": "K-Day", "plan_name": "PACE", "standard_charge_percentage": 100, "estimated_amount": 55547.25, "methodology": "fee schedule" } ], "minimum": 55547.25, "maximum": 72211.43 } ] }, { "description": "Multiple Level Spinal Fusion Except Cervical without MCC", "code_information": [ { "code": "448", "type": "MS-DRG" } ], 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California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 34201.7, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 34201.7, "methodology": "fee schedule" }, { "payer_name": "Imperial Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 34201.7, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 34201.7, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "C-SNP (Chronic Special Needs Plan)", "standard_charge_percentage": 100, "estimated_amount": 34201.7, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN Network", "standard_charge_percentage": 100, "estimated_amount": 36312.88, "methodology": "fee schedule" }, { 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"standard_charge_percentage": 100, "estimated_amount": 34201.7, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 41741.57, "methodology": "fee schedule" }, { "payer_name": "AltaMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 34201.7, "methodology": "fee schedule" }, { "payer_name": "Clever Care Health", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "estimated_amount": 34201.7, "methodology": "fee schedule" }, { "payer_name": "Anthem", "plan_name": "Medicare Advantage", "standard_charge_percentage": 106, "estimated_amount": 36253.8, "methodology": "fee schedule" }, { "payer_name": "Health Net of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 34201.7, "methodology": "fee schedule" }, { "payer_name": "California State Prison", "plan_name": "Prison 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"type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Alta Hospital Systems", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 74543.25, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "HMO", "standard_charge_percentage": 120, "estimated_amount": 89451.9, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 74543.25, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 74543.25, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "DSNP", "standard_charge_percentage": 100, "estimated_amount": 74543.25, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Self-Funded EPO/PPO", "standard_charge_percentage": 120, "estimated_amount": 89451.9, "methodology": "fee schedule" }, { "payer_name": "New Century Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 74543.25, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "L.A. Care Covered California", "standard_charge_percentage": 114.99999999999999, "estimated_amount": 85724.74, "methodology": "fee schedule" }, { "payer_name": "AHMC", "plan_name": "Senior HMO", "standard_charge_percentage": 100, "estimated_amount": 74543.25, "methodology": "fee schedule" }, { "payer_name": "Alignment", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 74543.25, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 74543.25, "methodology": "fee schedule" }, { "payer_name": "Asian Heritage PACE", "plan_name": "Duals", "standard_charge_percentage": 100, "estimated_amount": 74543.25, "methodology": "fee schedule" }, { "payer_name": "Pipeline formerly Avanti", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 74543.25, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 74543.25, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Commercial", "standard_charge_percentage": 100, "estimated_amount": 74543.25, "methodology": "fee schedule" }, { "payer_name": "Imperial Health Plan", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 74543.25, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 74543.25, "methodology": "fee schedule" }, { "payer_name": "Astiva Healthcare", "plan_name": "C-SNP (Chronic Special Needs Plan)", "standard_charge_percentage": 100, "estimated_amount": 74543.25, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN Network", "standard_charge_percentage": 100, "estimated_amount": 79144.61, "methodology": "fee schedule" }, { "payer_name": "LA Care", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 74543.25, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Special Needs Plan (SNP)", "standard_charge_percentage": 100, "estimated_amount": 74543.25, "methodology": "fee schedule" }, { "payer_name": "Easy Choice, dba WellCare of California", "plan_name": "Medicare Advantage Prescription Drug (MAPD)", "standard_charge_percentage": 100, "estimated_amount": 74543.25, "methodology": "fee schedule" }, { "payer_name": "Brand New Day", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 74543.25, "methodology": "fee schedule" }, { "payer_name": "Access Senior Healthcare", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 74543.25, "methodology": "fee schedule" }, { "payer_name": "UnitedHealthcare of California", "plan_name": "Medicare 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"plan_name": "Prison Healthcare Provider Network Project", "standard_charge_percentage": 125, "estimated_amount": 93179.06, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "estimated_amount": 74543.25, "methodology": "fee schedule" }, { "payer_name": "Central Health Plan of California", "plan_name": "Commercial", "standard_charge_percentage": 130, "estimated_amount": 96906.23, "methodology": "fee schedule" }, { "payer_name": "Medicare", "plan_name": "Medicare", "standard_charge_percentage": 100, "estimated_amount": 74543.25, "methodology": "fee schedule" }, { "payer_name": "K-Day", "plan_name": "PACE", "standard_charge_percentage": 100, "estimated_amount": 74543.25, "methodology": "fee schedule" } ], "minimum": 74543.25, "maximum": 96906.23 } ] }, { "description": "Spinal Fusion Except Cervical with Spinal Curvature, Malignancy, Infection or Extensive Fusions with CC", 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