{ "hospital_name": "UCLA West Valley Medical Center", "last_updated_on": "2025-06-28", "as_of_date": "2025-04-01", "version": "2.0.0", "hospital_location": [ "UCLA West Valley Medical Center" ], "hospital_address": [ "7300 Medical Center Drive, West Hills, CA 91307" ], "license_information": { "license_number": "930000028|CA", "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": "\"Silver Nitrate Applicator 6\"\"\"", "drug_information": { "unit": "1.000000", "type": "EA" }, "code_information": [ { "code": "12165010001", "type": "NDC" }, { "code": "12165010003", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 156.75, "gross_charge": 165.0, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.65, "standard_charge_percentage": 0.21, "methodology": "percent of total billed charges" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.94, "standard_charge_percentage": 0.436, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.8215, "standard_charge_percentage": 0.4171, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.75, "standard_charge_percentage": 0.35, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.485, "standard_charge_percentage": 0.409, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.5, "standard_charge_percentage": 0.7, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial Non B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.54, "standard_charge_percentage": 0.476, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.305, "standard_charge_percentage": 0.317, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.15, "standard_charge_percentage": 0.31, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.478, "standard_charge_percentage": 0.4332, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.8085, "standard_charge_percentage": 0.4049, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.02, "standard_charge_percentage": 0.388, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.295, "standard_charge_percentage": 0.323, "methodology": "percent of total billed charges" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 0.5, "methodology": "percent of total billed charges" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.7, "standard_charge_percentage": 0.38, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.75, "standard_charge_percentage": 0.95, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "per diem" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.65, "standard_charge_percentage": 0.21, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.277, "standard_charge_percentage": 0.4138, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.307, "standard_charge_percentage": 0.3958, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.75, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "UC Care", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.515, "standard_charge_percentage": 0.391, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.12, "standard_charge_percentage": 0.328, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.425, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.5, "standard_charge_percentage": 0.3, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.75, "standard_charge_percentage": 0.95, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "per diem" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.5995, "standard_charge_percentage": 0.4703, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.2335, "standard_charge_percentage": 0.4499, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Indemnity", "plan_name": "INDEMNITY", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.138, "standard_charge_percentage": 0.6372, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.0, "standard_charge_percentage": 0.4, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.56, "standard_charge_percentage": 0.464, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.94, "standard_charge_percentage": 0.436, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.75, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.425, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.5, "standard_charge_percentage": 0.3, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" } ], "additional_generic_notes": "" } ] }, { "description": "1 em core session", "code_information": [ { "code": "G9873", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 20.0, "maximum": 20.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "12-24hr sealed lead acid", "code_information": [ { "code": "K0733", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 28.9, "maximum": 28.9, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "1st hosp ip/obs high 75", "code_information": [ { "code": "99223", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 80.1, "maximum": 80.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "1st hosp ip/obs moderate 55", "code_information": [ { "code": "99222", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 73.2, "maximum": 73.2, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "1st hosp ip/obs sf/low 40", "code_information": [ { "code": "99221", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 34.3, "maximum": 34.3, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "1st nf care high mdm 50", "code_information": [ { "code": "99306", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 72.1, "maximum": 72.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "1st nf care moderate mdm 35", "code_information": [ { "code": "99305", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 46.9, "maximum": 46.9, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "1st nf care sf/low mdm 25", "code_information": [ { "code": "99304", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 37.8, "maximum": 37.8, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "1st plmt drug elut oc ins", "code_information": [ { "code": "0444T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 12065.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 4418.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 12065.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "1st psyc collab care mgmt", "code_information": [ { "code": "99492", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 111.37, "maximum": 158.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.5305, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.973, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.5305, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.3721, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.3721, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.913125, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.5305, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.68599, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.5305, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.5305, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.26, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "1st/sbsq psyc collab care", "code_information": [ { "code": "99494", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 57.88, "maximum": 57.88, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "2 em core ms mo 10-12 no wl", "code_information": [ { "code": "G9877", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 12.0, "maximum": 12.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "2 em core ms mo 10-12 wl", "code_information": [ { "code": "G9879", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 48.0, "maximum": 48.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "2 em core ms mo 7-9 no wl", "code_information": [ { "code": "G9876", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 12.0, "maximum": 12.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "2 em core ms mo 7-9 wl", "code_information": [ { "code": "G9878", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 48.0, "maximum": 48.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "2 em ongoing ms mo 13-15 wl", "code_information": [ { "code": "G9882", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 40.0, "maximum": 40.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "2 em ongoing ms mo 16-18 wl", "code_information": [ { "code": "G9883", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 40.0, "maximum": 40.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "2 em ongoing ms mo 19-21 wl", "code_information": [ { "code": "G9884", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 40.0, "maximum": 40.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "2 em ongoing ms mo 22-24 wl", "code_information": [ { "code": "G9885", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 40.0, "maximum": 40.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "2019-ncov diagnostic p", "code_information": [ { "code": "U0001", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 35.91, "maximum": 55.22, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.92, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.92, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.215745, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.92, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.8875, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.6035, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3738, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "22nf nonsealed leadacid", "code_information": [ { "code": "E2360", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 106.53, "maximum": 106.53, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "22nf sealed leadacid battery", "code_information": [ { "code": "E2361", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 128.24, "maximum": 128.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "2d cephal radio image", "code_information": [ { "code": "D0702", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 111.88, "maximum": 151.31, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.5358, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.8763, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.845375, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.3065, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.8763, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.5358, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.8763, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.014034, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.8763, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.8763, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "2d cephalometric image", "code_information": [ { "code": "D0340", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 111.88, "maximum": 151.31, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.845375, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.8763, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.8763, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.5358, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.8763, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.5358, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.014034, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.8763, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.3065, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.8763, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "2d oral/facial photo image", "code_information": [ { "code": "D0703", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 111.88, "maximum": 151.31, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.8763, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.8763, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.5358, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.845375, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.014034, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.8763, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.3065, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.8763, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.5358, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.8763, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "2d tee w or w/o fol w/con,in", "code_information": [ { "code": "C8925", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1000.4, "maximum": 1357.71, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 1003.8502, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 1184.543236, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 1003.8502, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1254.81275, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 1003.8502, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 1003.8502, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1000.3951, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1000.3951, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1003.8502, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 1357.7115, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "2d tte w or w/o fol w/con,co", "code_information": [ { "code": "C8923", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1000.4, "maximum": 1357.71, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 1003.8502, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1254.81275, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1000.3951, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 1003.8502, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 1003.8502, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 1357.7115, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1003.8502, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1000.3951, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 1003.8502, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 1184.543236, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "2vhpv vaccine 3 dose im", "code_information": [ { "code": "90650", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 132.59, "maximum": 397.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.116, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.59, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 397.2375, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.116, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.116, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "3-d radiotherapy plan", "code_information": [ { "code": "77295", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 328.88, "maximum": 2351.36, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2173.139, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 1738.5112, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 2051.443216, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1731.2442, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem 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"standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1731.2442, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 429.75, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 328.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "365 d implant glucose sensor", "code_information": [ { "code": "G0564", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 4130.09, "maximum": 7838.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem Medicare 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"standard_charge_percentage": 0.388, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.468, "standard_charge_percentage": 0.323, "methodology": "percent of total billed charges" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 0.5, "methodology": "percent of total billed charges" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.08, "standard_charge_percentage": 0.38, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.824, "standard_charge_percentage": 0.464, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health 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"additional_payer_notes": "N/A", "standard_charge_dollar": 54.5548, "standard_charge_percentage": 0.4703, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.1884, "standard_charge_percentage": 0.4499, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.2, "standard_charge_percentage": 0.95, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "per diem" }, { "payer_name": "Anthem Indemnity", "plan_name": "INDEMNITY", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.9152, "standard_charge_percentage": 0.6372, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.42, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.8, "standard_charge_percentage": 0.3, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.2, "standard_charge_percentage": 0.95, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "per diem" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Abatacept injection", "code_information": [ { "code": "J0129", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 41.21, "maximum": 116.98, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.761, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.1186, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": 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}, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.1186, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.2592, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.211, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Abciximab injection", "code_information": [ { "code": "J0130", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1375.15, "maximum": 3822.76, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1375.147, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1375.147, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 1375.147, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3822.7622, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Abdominal pad", "code_information": [ { "code": "L1270", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 56.61, "maximum": 56.61, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.61, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Abduct control hip semi-flex", "code_information": [ { "code": "L1630", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 77.6, "maximum": 77.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Abduct rotation bar w/o shoe", "code_information": [ { "code": "L3150", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 51.17, "maximum": 51.17, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Abduction bar jointed adjust", "code_information": [ { "code": "L2300", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 216.18, "maximum": 216.18, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.18, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Abduction bar-straight", "code_information": [ { "code": "L2310", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 98.78, "maximum": 98.78, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Abduction rotation bar shoe", "code_information": [ { "code": "L3140", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 55.97, "maximum": 55.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "ABETA42 & PTAU181 ECLIA CSF", "code_information": [ { "code": "0445U", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 260.5, "maximum": 260.5, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 260.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ABETA42 & TTAU ECLIA CSF", "code_information": [ { "code": "0459U", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 260.5, "maximum": 260.5, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 260.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Abl lsr opn wnd 1st 20 sqcm", "code_information": [ { "code": "0491T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 4418.0, "maximum": 7473.32, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 4418.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 5610.51, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5610.51, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7473.32, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Abl lsr opn wnd addl 20 sqcm", "code_information": [ { "code": "0492T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 4418.0, "maximum": 7473.32, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { 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"gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 461.1165, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Ablate atria lmtd", "code_information": [ { "code": "33254", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 7978.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7978.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", 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"additional_generic_notes": "" } ] }, { "description": "Abltj mal brst tum perq crtx", "code_information": [ { "code": "0581T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1132.89, "maximum": 14129.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 11454.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1132.89, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 5741.270176, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", 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100.0, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 3518.193, "standard_charge_percentage": 0.327, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 4400.431, "standard_charge_percentage": 0.409, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7531.3, "standard_charge_percentage": 0.7, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Indemnity", "plan_name": "INDEMNITY", "additional_payer_notes": "N/A", "standard_charge_dollar": 6855.6348, "standard_charge_percentage": 0.6372, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Acamprosate Calc Dr 333 MG Tab", "drug_information": { "unit": "333.000000", "type": "ME" }, "code_information": [ { "code": "00378633380", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 14.51, "gross_charge": 15.27, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.24543, "standard_charge_percentage": 0.409, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { 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"standard_charge_dollar": 8.3985, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "OPPS - Bundled" } ] }, { "description": "Access thoracic lymph duct", "code_information": [ { "code": "38794", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 4418.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, 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"payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.038892, "standard_charge_percentage": 0.4703, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.128636, "standard_charge_percentage": 0.4499, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Accupril 20 MG Tablet", "drug_information": { "unit": "20.000000", "type": "ME" }, "code_information": [ { "code": "00071053223", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 87.78, "gross_charge": 92.4, "discounted_cash": 0.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.8736, 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billed charges" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.384, "standard_charge_percentage": 0.95, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "per diem" }, { "payer_name": "Anthem Indemnity", "plan_name": "INDEMNITY", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.513984, "standard_charge_percentage": 0.6372, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.3464, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.016, "standard_charge_percentage": 0.3, "methodology": "percent of total billed charges" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" } ], "additional_generic_notes": "" } ] }, { "description": "Acellular derm matrix implt", "code_information": [ { "code": "15777", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 6302.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 4418.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, 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1009.25, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1009.25, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 711.98, "standard_charge_percentage": 0.388, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 592.705, "standard_charge_percentage": 0.323, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 600.045, "standard_charge_percentage": 0.327, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All 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California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.008, "standard_charge_percentage": 0.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Acetaminophen 325 MG/10.15 Ml Cup", "drug_information": { "unit": "650.000000", "type": "ME" }, "code_information": [ { "code": "00121131400", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 3.38, "gross_charge": 3.56, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Anthem Indemnity", "plan_name": "INDEMNITY", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.268432, "standard_charge_percentage": 0.6372, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care 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"additional_payer_notes": "N/A", "standard_charge_dollar": 1.424, "standard_charge_percentage": 0.4, "methodology": "percent of total billed charges" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.542192, "standard_charge_percentage": 0.4332, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.441444, "standard_charge_percentage": 0.4049, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.65184, "standard_charge_percentage": 0.464, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", 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"standard_charge_percentage": 100.0, "methodology": "other" } ], "additional_generic_notes": "" } ] }, { "description": "Acetaminophen-Cod #3 Tablet", "drug_information": { "unit": "1.000000", "type": "EA" }, "code_information": [ { "code": "00406048401", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 34.34, "gross_charge": 36.15, "discounted_cash": 0.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.7736, "standard_charge_percentage": 0.464, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.7614, "standard_charge_percentage": 0.436, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of 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charges" } ], "additional_generic_notes": "" } ] }, { "description": "Acetaminophen-Codeine 300-30 MG/12.5 Ml Cup", "drug_information": { "unit": "12.500000", "type": "EA" }, "code_information": [ { "code": "00121100800", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 14.9, "gross_charge": 15.68, "discounted_cash": 0.01, "setting": "both", "payers_information": [ { "payer_name": "Anthem Indemnity", "plan_name": "INDEMNITY", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.991296, "standard_charge_percentage": 0.6372, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.488384, "standard_charge_percentage": 0.4138, 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sodium injectio", "code_information": [ { "code": "J1120", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 30.78, "maximum": 64.31, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.7115, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.7115, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.307, "standard_charge_percentage": 100.0, 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"methodology": "other" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.491682, "standard_charge_percentage": 0.4703, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.819706, "standard_charge_percentage": 0.4499, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "OPPS - Bundled" } ] }, { "description": "Acetylcysteine injection", "code_information": [ { "code": "J0132", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.43, "maximum": 5.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.425, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.425, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.425, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.5247, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Acetylcysteine non-comp unit", "code_information": [ { "code": "J7608", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 12.64, "maximum": 24.37, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.6395, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.3692, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.6395, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.6395, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Acid perfusion of esophagus", "code_information": [ { "code": "91030", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 40.46, "maximum": 1511.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 674.1804, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 674.1804, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", 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"standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 4418.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1132.89, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 252.4682, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1244.0, 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"N/A", "standard_charge_dollar": 1509.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 1132.89, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.1381, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1244.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 252.4682, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 252.4682, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 297.912476, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.4775, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Acoustic immitance testing", "code_information": [ { "code": "92570", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 26.84, "maximum": 268.87, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.7981, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.1667, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.1667, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 248.497625, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.7981, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.869, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.7981, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.7981, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.7981, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 234.581758, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Acoustic refl threshold tst", "code_information": [ { "code": "92568", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 9.28, "maximum": 67.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.847898, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.8711, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.8711, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.1063, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.8711, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.8711, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.8711, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.4595, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.1063, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.338875, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Actemra 200 MG/10 Ml Vial", "drug_information": { "unit": "200.000000", "type": "ME" }, "code_information": [ { "code": "50242013601", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 2701.3, "gross_charge": 3859.0, "discounted_cash": 0.01, "setting": "inpatient", "payers_information": [ { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1682.524, "standard_charge_percentage": 0.436, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1609.5889, "standard_charge_percentage": 0.4171, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1790.576, "standard_charge_percentage": 0.464, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1682.524, "standard_charge_percentage": 0.436, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 945.455, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.7745, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1350.65, "standard_charge_percentage": 0.35, "methodology": "percent of total billed charges" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1929.5, "standard_charge_percentage": 0.5, "methodology": "percent of total billed charges" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1466.42, "standard_charge_percentage": 0.38, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 957.032, "standard_charge_percentage": 0.248, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.08, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "other" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", 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"standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" } ], "additional_generic_notes": "" } ] }, { "description": "Adalimumab injection", "code_information": [ { "code": "J0135", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1834.49, "maximum": 2773.99, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1834.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2773.992, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2773.992, "standard_charge_percentage": 100.0, "methodology": "fee 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"estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 239.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.825, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11115.856, "standard_charge_percentage": 0.248, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.08, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "other" } ], "additional_generic_notes": "" } ] }, { "description": "Add le poly knee custom kafo", "code_information": [ { "code": "L2387", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 132.88, "maximum": 132.88, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Add proc construct new crown", "code_information": [ { "code": "D2971", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1100.08, "maximum": 2857.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 2112.5377, "standard_charge_percentage": 100.0, "methodology": "fee schedule" 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"standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 2112.5377, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2640.672125, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 2112.5377, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 2857.239, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Add pwr joystick", "code_information": [ { "code": "E0983", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 2862.96, "maximum": 2862.96, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 2862.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Add pwr leg elevation", "code_information": [ { "code": "E1010", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1143.79, "maximum": 1143.79, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1143.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Add pwr tiller", "code_information": [ { "code": "E0984", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1623.99, "maximum": 1623.99, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1623.99, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Add ue prost a/e acrylic", "code_information": [ { "code": "L7404", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 350.06, "maximum": 350.06, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 350.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], 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"methodology": "case rate" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 949.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 9076.8233, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 9076.8233, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9076.8233, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21589.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 10710.651494, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 20960.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 9076.8233, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 12065.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7473.32, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 20495.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20960.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8938.5262, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8938.5262, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5610.51, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4780.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11346.029125, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 5610.51, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 12276.546, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Adjust knee ext/flex device", "code_information": [ { "code": "E1810", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1195.97, "maximum": 1195.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1195.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Adjustable angle footplate", "code_information": [ { "code": "K0040", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 63.88, "maximum": 63.88, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Adjustment gastric band", "code_information": [ { "code": "S2083", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 4418.0, "maximum": 6302.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 6302.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 4418.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Adm of soc dtr assess 5-15 m", "code_information": [ { "code": "G0136", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 35.85, "maximum": 51.2, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.852, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.8512, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.852, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.8512, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.314, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.8512, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.8512, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.8512, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.1955, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.664416, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Adm tocilizu covid-19 1st", "code_information": [ { "code": "M0249", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 427.98, "maximum": 715.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 572.4053, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 590.7587, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 590.7587, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 572.4053, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 572.4053, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 675.438254, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 427.975, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 715.506625, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 572.4053, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 572.4053, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Adm tocilizu covid-19 2nd", "code_information": [ { "code": "M0250", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 427.98, "maximum": 715.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 572.4053, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 715.506625, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 572.4053, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 572.4053, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 590.7587, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 572.4053, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 572.4053, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 675.438254, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 590.7587, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 427.975, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Admin ecg contrast agent", "code_information": [ { "code": "93352", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 34.77, "maximum": 34.77, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.77, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Admin hepatitis b vaccine", "code_information": [ { "code": "G0010", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 58.63, "maximum": 79.29, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.6255, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.3512, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.3512, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.281875, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.6255, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.6255, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.6255, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.17809, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.6255, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.287, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Admn sarscov2 vacc 1 dose", "code_information": [ { "code": "90480", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 30.42, "maximum": 71.35, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.7553, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.4468, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.4468, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.4215, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.7553, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.944125, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.4215, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.251254, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.345, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.4215, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.7553, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.7553, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.7553, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Adrc ther prtl rc tear", "code_information": [ { "code": "0717T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 4482.5, "maximum": 21589.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 4651.6285, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21589.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": 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"standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Adrenalin 1 MG/Ml Nasal Soln", "drug_information": { "unit": "1.000000", "type": "EA" }, "code_information": [ { "code": "42023010301", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 188.1, "gross_charge": 198.0, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.51, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.4, "standard_charge_percentage": 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"additional_payer_notes": "N/A", "standard_charge_dollar": 1112.3, "standard_charge_percentage": 0.7, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial Non B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 756.364, "standard_charge_percentage": 0.476, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.95, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Advair 500-50 Diskus", "drug_information": { "unit": "1.000000", "type": "EA" }, "code_information": [ { "code": "00173069704", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 2099.5, "gross_charge": 2210.0, "discounted_cash": 0.01, "setting": 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"additional_payer_notes": "N/A", "standard_charge_dollar": 963.56, "standard_charge_percentage": 0.436, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 921.791, "standard_charge_percentage": 0.4171, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 864.11, "standard_charge_percentage": 0.391, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 724.88, "standard_charge_percentage": 0.328, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2099.5, "standard_charge_percentage": 0.95, 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"additional_payer_notes": "N/A", "standard_charge_dollar": 857.48, "standard_charge_percentage": 0.388, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 713.83, "standard_charge_percentage": 0.323, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1039.363, "standard_charge_percentage": 0.4703, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 994.279, "standard_charge_percentage": 0.4499, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1025.44, "standard_charge_percentage": 0.464, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 963.56, "standard_charge_percentage": 0.436, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Indemnity", "plan_name": "INDEMNITY", "additional_payer_notes": "N/A", "standard_charge_dollar": 1408.212, "standard_charge_percentage": 0.6372, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 541.45, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 663.0, "standard_charge_percentage": 0.3, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1215.5, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 773.5, "standard_charge_percentage": 0.35, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 903.89, "standard_charge_percentage": 0.409, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1547.0, "standard_charge_percentage": 0.7, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Advanced life support mileag", "code_information": [ { "code": "A0390", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1.3, "maximum": 1.3, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Advncd care plan 30 min", "code_information": [ { "code": "99497", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 69.59, "maximum": 158.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.5305, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.3721, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.68599, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.973, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.5305, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.3721, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.913125, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.5305, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.59, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.5305, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.5305, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Advncd care plan addl 30 min", "code_information": [ { "code": "99498", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 62.64, "maximum": 62.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Aep hearing status deter i&r", "code_information": [ { "code": "92651", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 80.62, "maximum": 535.14, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 395.6648, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 395.6648, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 395.6648, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 392.1693, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 494.581, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 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"standard_charge_dollar": 494.581, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 395.6648, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.92, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Aep scr auditory potential", "code_information": [ { "code": "92650", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 25.68, "maximum": 25.68, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Aep thrshld est mlt freq i&r", "code_information": [ { "code": "92652", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 104.64, "maximum": 535.14, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 395.6648, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 392.1693, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 395.6648, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 395.6648, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 466.884464, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 494.581, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 395.6648, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 535.135, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 395.6648, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 392.1693, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Aerosol inhalation treatment", "code_information": [ { "code": "94642", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 85.9, "maximum": 349.53, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 258.4273, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.944214, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 266.4905, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 323.034125, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { 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"standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 258.4273, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Aerosol mask used w nebulize", "code_information": [ { "code": "A7015", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1.79, "maximum": 1.79, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Afamelanotide implant, 1 mg", "code_information": [ { "code": "J7352", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 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"payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 756.067, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 835.4, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 967.0875, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 969.9364, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 872.7, "standard_charge_percentage": 100.0, "methodology": 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}, { "description": "Afo molded to patient plasti", "code_information": [ { "code": "L1940", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 347.88, "maximum": 347.88, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Afo multilig ank sup pre ots", "code_information": [ { "code": "L1906", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 96.56, "maximum": 96.56, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Afo plastic", "code_information": [ { "code": "L1930", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 132.43, "maximum": 132.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Afo plastic molded w/ankle j", "code_information": [ { "code": "L1970", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 449.28, "maximum": 449.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 449.28, "standard_charge_percentage": 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"standard_charge_dollar": 560.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Afo sing bar clasp attach sh", "code_information": [ { "code": "L1910", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 147.95, "maximum": 147.95, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Afo sing solid stirrup calf", "code_information": [ { "code": "L1980", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 235.66, "maximum": 235.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", 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total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.1732, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.008, "standard_charge_percentage": 0.3, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.692, "standard_charge_percentage": 0.95, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "per diem" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", 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billed charges" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.3416, "standard_charge_percentage": 0.31, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.348, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "After cataract laser surgery", "code_information": [ { "code": "66821", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 301.49, "maximum": 7838.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7838.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4442.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 301.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4810.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 697.0512, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 822.520416, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC National", "plan_name": 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"payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 942.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 871.314, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 4418.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4313.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 697.0512, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4810.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 697.0512, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 726.2594, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6539.15, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 4909.2, 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Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 599.9, "standard_charge_percentage": 0.35, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 359.94, "standard_charge_percentage": 0.21, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 419.93, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 514.2, "standard_charge_percentage": 0.3, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 685.6, "standard_charge_percentage": 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"EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 419.93, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 514.2, "standard_charge_percentage": 0.3, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" } ], "additional_generic_notes": "OPPS - Bundled" } ] }, { "description": "Albumin (human), 25%, 20 ml", "code_information": [ { "code": "P9046", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 20.17, "maximum": 75.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", 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"payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.0514, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Albumin (human), 25%, 50ml", "code_information": [ { "code": "P9047", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 53.08, "maximum": 122.78, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.7825, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Albumin (human), 5%, 250 ml", "code_information": [ { "code": "P9045", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 50.43, "maximum": 127.04, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.35, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.0357, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.4434, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.4434, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.6344, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.426, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Albumin (human),5%, 50ml", "code_information": [ { "code": "P9041", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 10.62, "maximum": 89.48, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.4787, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": 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"outpatient", "payers_information": [ { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.165282, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.7526, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Alburx (Human) 5% Vial", "drug_information": { "unit": "12.500000", "type": "GR" }, "code_information": [ { "code": "44206031025", "type": "NDC" }, { "code": "44206031050", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 1817.2, "gross_charge": 2596.0, "discounted_cash": 0.01, "setting": "inpatient", "payers_information": [ { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1131.856, "standard_charge_percentage": 0.436, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", 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"plan_name": "INDEMNITY", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.783848, "standard_charge_percentage": 0.6372, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4533, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.902, "standard_charge_percentage": 0.3, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial Non B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.53784, "standard_charge_percentage": 0.476, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": 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"other" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.487, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.22176, "standard_charge_percentage": 0.464, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.48424, "standard_charge_percentage": 0.436, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4533, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.902, "standard_charge_percentage": 0.3, "methodology": "percent of total billed charges" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.17, "standard_charge_percentage": 0.5, "methodology": "percent of total billed charges" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.0092, "standard_charge_percentage": 0.38, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.387702, "standard_charge_percentage": 0.4703, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.850366, "standard_charge_percentage": 0.4499, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Albuterol comp con", "code_information": [ { "code": "J7610", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 3.29, "maximum": 3.29, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2902, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Albuterol comp unit", "code_information": [ { "code": "J7609", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1.36, "maximum": 1.36, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.3642, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Albuterol Hfa 90 Mcg Inhaler", "drug_information": { "unit": "1.000000", "type": "EA" }, "code_information": [ { "code": "00054074287", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 4.57, "gross_charge": 4.81, "discounted_cash": 0.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.52477, "standard_charge_percentage": 0.317, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.4911, "standard_charge_percentage": 0.31, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.924, "standard_charge_percentage": 0.4, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": 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PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.28956, "standard_charge_percentage": 0.476, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.405, "standard_charge_percentage": 0.5, "methodology": "percent of total billed charges" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.8278, "standard_charge_percentage": 0.38, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.0101, 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Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.903798, "standard_charge_percentage": 0.3958, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.6455, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.23184, "standard_charge_percentage": 0.464, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.09716, "standard_charge_percentage": 0.436, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.262143, "standard_charge_percentage": 0.4703, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.164019, "standard_charge_percentage": 0.4499, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.88071, "standard_charge_percentage": 0.391, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.57768, "standard_charge_percentage": 0.328, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.17845, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.443, "standard_charge_percentage": 0.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Albuterol ipratrop non-comp", "code_information": [ { "code": "J7620", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.41, "maximum": 0.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.408, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.408, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.5082, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.408, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Albuterol non-comp con", "code_information": [ { "code": "J7611", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.12, "maximum": 0.53, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.4547, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.527, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.527, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.527, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Albuterol non-comp unit", "code_information": [ { "code": "J7613", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.04, "maximum": 0.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.1337, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.04, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.5355, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.5355, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.5355, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Albuterol Sul 1.25 MG/3 Ml Sol", "drug_information": { "unit": "1.250000", "type": "ME" }, "code_information": [ { "code": "00487990401", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 41.71, "gross_charge": 43.9, "discounted_cash": 0.01, "setting": "inpatient", "payers_information": [ { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.1404, "standard_charge_percentage": 0.436, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC HMO", "plan_name": "HMO", 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"methodology": "percent of total billed charges" }, { "payer_name": "Anthem Indemnity", "plan_name": "INDEMNITY", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.928, "standard_charge_percentage": 0.6372, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.312, "standard_charge_percentage": 0.4138, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.992, "standard_charge_percentage": 0.3958, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Aliskiren 150 MG Tablet", "drug_information": { "unit": "150.000000", "type": "ME" }, "code_information": [ { "code": "49884042411", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 53.39, "gross_charge": 56.2, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.91, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.67, "standard_charge_percentage": 0.35, "methodology": 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"standard_charge_percentage": 0.3958, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.769, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.86, "standard_charge_percentage": 0.3, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.48, "standard_charge_percentage": 0.4, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.0768, "standard_charge_percentage": 0.464, "estimated_amount": 999999999.0, 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999999999.0, "methodology": "other" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.3745, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Allegra Allergy 60 MG Tablet", "drug_information": { "unit": "60.000000", "type": "ME" }, "code_information": [ { "code": "41167041312", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 72.75, "gross_charge": 76.58, "discounted_cash": 0.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.53312, "standard_charge_percentage": 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"standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Alternating pressure pad", "code_information": [ { "code": "A4640", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 45.18, "maximum": 45.18, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.18, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Altuviiio per factor viii iu", "code_information": [ { "code": "J7214", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 4.37, "maximum": 12.57, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.69, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.8448, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.5342, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.5725, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.576, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.576, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.8448, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.576, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.8625, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.69, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.69, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Alveoloplasty not w/extracts", "code_information": [ { "code": "D7321", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1882.11, "maximum": 2545.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1882.1144, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2352.643, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 1882.1144, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", 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"UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 1882.1144, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 1882.1144, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1882.1144, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Alveolus clsd reduc stblz te", "code_information": [ { "code": "D7771", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 4022.69, "maximum": 5573.23, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 4120.6447, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 4862.360746, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 5573.232, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5150.805875, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4022.6928, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 4120.6447, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 4120.6447, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4120.6447, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4022.6928, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 4120.6447, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Alveolus open reduction", "code_information": [ { "code": "D7671", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 7316.9, "maximum": 10166.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 7516.4376, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7316.8969, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9395.547, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 7516.4376, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 7516.4376, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 7516.4376, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7516.4376, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7316.8969, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 10166.102, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 8869.396368, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Alveoplasty w/ extraction", "code_information": [ { "code": "D7310", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 666.76, "maximum": 2545.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2352.643, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 1882.1144, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1905.4426, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1905.4426, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 1882.1144, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 2220.894992, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 2545.601, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1882.1144, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 1882.1144, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 666.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 1882.1144, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Alveoplasty w/o extraction", "code_information": [ { "code": "D7320", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1882.11, "maximum": 2545.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 1882.1144, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 2545.601, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 1882.1144, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 2220.894992, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2352.643, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 1882.1144, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 1882.1144, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1882.1144, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Alys brn npgt prgrmg 15 min", "code_information": [ { "code": "95983", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 43.92, "maximum": 157.74, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.9449, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.6284, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.92, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.6284, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.6284, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.6284, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.6284, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.9449, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.7855, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.738, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.621512, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Alys brn npgt prgrmg addl 15", "code_information": [ { "code": "95984", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 38.29, "maximum": 38.29, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.29, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Alys cplx cn npgt prgrmg", "code_information": [ { "code": "95977", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 46.54, "maximum": 157.74, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.6284, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.9449, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.738, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.6284, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.7855, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.6284, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.6284, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.9449, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.6284, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.621512, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Alys cplx sp/pn npgt w/prgrm", "code_information": [ { "code": "95972", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 64.73, "maximum": 157.74, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.6284, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.9449, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.6284, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.738, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.6284, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.6284, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.6284, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.621512, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.9449, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.7855, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Alys npgt w/o prgrmg", "code_information": [ { "code": "95970", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 19.79, "maximum": 221.52, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.6032, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.7803, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.7803, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.6032, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.7803, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.260754, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.725375, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.7803, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.7803, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.521, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Alys smpl cn npgt prgrmg", "code_information": [ { "code": "95976", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 35.02, "maximum": 64.09, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.3807, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.3807, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.3807, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.087, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.225875, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.3807, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.3807, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.909226, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.1164, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.1164, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Alys smpl sp/pn npgt w/prgrm", "code_information": [ { "code": "95971", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 33.72, "maximum": 157.74, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.6284, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.9449, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.6284, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.738, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.6284, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.6284, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.9449, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.6284, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.621512, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.7855, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Amalgam 4 or > surfaces perm", "code_information": [ { "code": "D2161", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1100.08, "maximum": 2857.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2112.5377, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2640.672125, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 2112.5377, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1100.0831, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 2112.5377, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 2112.5377, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1100.0831, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 2492.794486, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 2112.5377, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 2857.239, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Amalgam one surface permanen", "code_information": [ { "code": "D2140", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1100.08, "maximum": 2857.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 2492.794486, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2112.5377, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1100.0831, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 2112.5377, "standard_charge_percentage": 100.0, "methodology": 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"standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 2857.239, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Amalgam three surfaces perma", "code_information": [ { "code": "D2160", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1100.08, "maximum": 2857.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2112.5377, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 2492.794486, "standard_charge_percentage": 100.0, "methodology": "fee 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"standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" } ], "additional_generic_notes": "" } ] }, { "description": "Amb infusion pump mechanical", "code_information": [ { "code": "E0779", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 153.88, "maximum": 153.88, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Ambien 5 MG Tablet", "drug_information": { "unit": "5.000000", "type": "ME" }, "code_information": [ { "code": "00024540131", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 49.48, "gross_charge": 52.08, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": 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of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.228, "standard_charge_percentage": 0.35, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.30072, "standard_charge_percentage": 0.409, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.456, "standard_charge_percentage": 0.7, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Indemnity", "plan_name": "INDEMNITY", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.185376, "standard_charge_percentage": 0.6372, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Select_Select Plus", "plan_name": 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999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 785.6, "standard_charge_percentage": 0.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ambl bp mntr w/software", "code_information": [ { "code": "93784", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 48.4, "maximum": 48.4, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.4, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Ambl bp mntr w/sw a/r", "code_information": [ { "code": "93788", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 4.81, "maximum": 221.52, 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Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" } ], "additional_generic_notes": "" } ] }, { "description": "Amikacin sulfate injection", "code_information": [ { "code": "J0278", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1.58, "maximum": 5.4, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.1132, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.4, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.581, 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California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.6, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.0, "standard_charge_percentage": 0.3, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.64, "standard_charge_percentage": 0.248, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.08, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "other" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 374.0, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.0, "standard_charge_percentage": 0.35, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.64, "standard_charge_percentage": 0.248, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.08, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "other" }, { "payer_name": "UC Ship", 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}, { "payer_name": "UC Care", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.04, "standard_charge_percentage": 0.328, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial Non B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 323.68, "standard_charge_percentage": 0.476, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 281.384, "standard_charge_percentage": 0.4138, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 269.144, "standard_charge_percentage": 0.3958, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" } ], "additional_generic_notes": "" } ] }, { "description": "Aminolevulinic acid hcl top", "code_information": [ { "code": "J7308", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 374.69, "maximum": 1057.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 396.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 392.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 395.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 396.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 401.081, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 401.081, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 401.081, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": 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"payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 501.1373, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.4246, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 374.6895, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Aminolevulinic acid, 10% gel", "code_information": [ { "code": "J7345", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1.65, "maximum": 4.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.6545, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.2617, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.853, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", 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"LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.0296, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Aminophyllin 250 mg inj", "code_information": [ { "code": "J0280", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 12.26, "maximum": 35.26, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2565, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.257, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.257, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.257, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Aminophylline 250 MG/10 Ml Vl", "drug_information": { "unit": "250.000000", "type": "ME" }, "code_information": [ { "code": "00409592101", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 62.87, "gross_charge": 89.81, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.4335, "standard_charge_percentage": 0.35, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.73229, "standard_charge_percentage": 0.409, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.867, "standard_charge_percentage": 0.7, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.8601, "standard_charge_percentage": 0.21, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 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"plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.459751, "standard_charge_percentage": 0.4171, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.237643, "standard_charge_percentage": 0.4703, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.405519, "standard_charge_percentage": 0.4499, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.11571, "standard_charge_percentage": 0.391, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.45768, "standard_charge_percentage": 0.328, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Indemnity", "plan_name": "INDEMNITY", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.226932, "standard_charge_percentage": 0.6372, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial Non B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.74956, "standard_charge_percentage": 0.476, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.163378, "standard_charge_percentage": 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"additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.896, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.24, "standard_charge_percentage": 0.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Amitriptyline HCl 100 MG Tab", "drug_information": { "unit": "100.000000", "type": "ME" }, "code_information": [ { "code": "00378268501", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 10.57, "gross_charge": 11.13, "discounted_cash": 0.01, "setting": "inpatient", "payers_information": [ { "payer_name": "UC Care", "plan_name": "PPO", 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"standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.72403, "standard_charge_percentage": 0.409, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.469, "standard_charge_percentage": 0.7, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.967246, "standard_charge_percentage": 0.4138, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.055186, "standard_charge_percentage": 0.3958, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.268, "standard_charge_percentage": 0.4, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.6407, "standard_charge_percentage": 0.21, "methodology": "percent of total billed charges" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.09212, "standard_charge_percentage": 0.436, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.134457, "standard_charge_percentage": 0.4171, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.950244, "standard_charge_percentage": 0.4332, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.516283, "standard_charge_percentage": 0.4049, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.1365, "standard_charge_percentage": 0.95, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "per diem" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.8685, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.8685, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ammonium Lactate 12% Lotion", "drug_information": { "unit": "1.000000", "type": "EA" }, "code_information": [ { "code": "00904598426", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 469.3, "gross_charge": 494.0, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.74, "standard_charge_percentage": 0.21, "methodology": "percent of total billed charges" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.384, "standard_charge_percentage": 0.436, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 206.0474, "standard_charge_percentage": 0.4171, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of 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"standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "per diem" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Anthem Indemnity", "plan_name": "INDEMNITY", "additional_payer_notes": "N/A", "standard_charge_dollar": 314.7768, "standard_charge_percentage": 0.6372, "methodology": "percent of total billed charges" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.672, "standard_charge_percentage": 0.388, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.562, "standard_charge_percentage": 0.323, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.598, "standard_charge_percentage": 0.317, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.14, "standard_charge_percentage": 0.31, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 271.7, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 271.7, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.6, "standard_charge_percentage": 0.4, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 214.0008, "standard_charge_percentage": 0.4332, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.0206, "standard_charge_percentage": 0.4049, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.216, "standard_charge_percentage": 0.464, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.384, "standard_charge_percentage": 0.436, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 469.3, "standard_charge_percentage": 0.95, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "per diem" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.03, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.2, "standard_charge_percentage": 0.3, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net Commercial Non B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.144, "standard_charge_percentage": 0.476, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.4172, "standard_charge_percentage": 0.4138, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.5252, "standard_charge_percentage": 0.3958, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.0, "standard_charge_percentage": 0.5, "methodology": "percent of total billed charges" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.72, "standard_charge_percentage": 0.38, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.74, "standard_charge_percentage": 0.21, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.154, "standard_charge_percentage": 0.391, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.032, "standard_charge_percentage": 0.328, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 202.046, "standard_charge_percentage": 0.409, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 345.8, "standard_charge_percentage": 0.7, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 232.3282, "standard_charge_percentage": 0.4703, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.2506, "standard_charge_percentage": 0.4499, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Amnicore pro+, per sq cm", "code_information": [ { "code": "Q4299", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 6379.88, "maximum": 6379.88, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6379.875, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Amnicore pro, per sq cm", "code_information": [ { "code": "Q4298", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 5812.78, "maximum": 5812.78, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5812.775, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Amnio or derma tl, per sq cm", "code_information": [ { "code": "Q4225", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 3956.33, "maximum": 3956.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3956.325, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Amnio quad-core, per sq cm", "code_information": [ { "code": "Q4294", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 6096.33, "maximum": 6096.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6096.325, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Amnio tri-core, per sq cm", "code_information": [ { "code": "Q4295", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 5529.23, "maximum": 5529.23, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5529.225, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Amnio-maxx or lite per sq cm", "code_information": [ { "code": "Q4239", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 6379.88, "maximum": 6379.88, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6379.875, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Amnioamp-mp per sq cm", "code_information": [ { "code": "Q4250", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 5570.69, "maximum": 5570.69, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5570.6875, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Amnioarmor 1 sq cm", "code_information": [ { "code": "Q4188", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1132.89, "maximum": 1509.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 1132.89, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1132.89, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1453.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Amnioband, 1 mg", "code_information": [ { "code": "Q4168", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 45.61, "maximum": 45.61, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.6087, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Amnioband, guardian 1 sq cm", "code_information": [ { "code": "Q4151", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 120.84, "maximum": 386.38, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 386.377, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Amniocentesis diagnostic", "code_information": [ { "code": "59000", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 62.25, "maximum": 6302.0, "gross_charge": 0.01, 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schedule" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 386.5038, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Amniocore per sq cm", "code_information": [ { "code": "Q4227", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 290.89, "maximum": 2778.79, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": 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"standard_charges": [ { "minimum": 150.55, "maximum": 401.17, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 401.1697, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Amniotext patch, per sq cm", "code_information": [ { "code": "Q4247", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 530.0, "maximum": 3242.37, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 530.0, 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"plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.35, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.377376, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.35, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Amniowrap2 per sq cm", "code_information": [ { "code": "Q4221", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 4962.13, "maximum": 4962.13, "gross_charge": 0.01, 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"plan_name": "INDEMNITY", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.999872, "standard_charge_percentage": 0.6372, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.61888, "standard_charge_percentage": 0.388, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.82448, "standard_charge_percentage": 0.323, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.521888, "standard_charge_percentage": 0.4138, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", 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"payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 256.85, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.597, "standard_charge_percentage": 0.391, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.176, "standard_charge_percentage": 0.328, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.816, "standard_charge_percentage": 0.248, "estimated_amount": 999999999.0, 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"additional_payer_notes": "N/A", "standard_charge_dollar": 16.435, "standard_charge_percentage": 0.38, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.7875, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" } ], "additional_generic_notes": "" } ] }, { "description": "Ampicillin sulbactam 1.5 gm", "code_information": [ { "code": "J0295", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 4.28, "maximum": 5.19, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.284, 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"type": "HCPCS" }, { "code": "27592", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 4909.2, "maximum": 28055.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27238.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28055.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 26633.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 4909.2, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { 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"additional_generic_notes": "" } ] }, { "description": "Amputate lower leg at knee", "code_information": [ { "code": "27598", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 3668.41, "maximum": 27172.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27172.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7978.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", 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"standard_charge_dollar": 7978.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 4122.6015, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 4122.6015, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 4864.66977, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Amputate upper arm & implant", "code_information": [ { "code": "24931", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 3668.41, "maximum": 27172.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26381.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 26381.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27172.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7978.0, "standard_charge_percentage": 100.0, "methodology": 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}, { "code": "27596", "type": "HCPCS" }, { "code": "27886", "type": "HCPCS" }, { "code": "24925", "type": "HCPCS" }, { "code": "24930", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 949.0, "maximum": 27172.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 12065.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 4122.6015, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 9076.8233, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": 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"ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7978.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Amputation of lower leg", "code_information": [ { "code": "27880", "type": "HCPCS" }, { "code": "27881", "type": "HCPCS" }, { "code": "27882", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 3668.41, "maximum": 28055.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 26633.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 25795.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": 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"additional_payer_notes": "N/A", "standard_charge_dollar": 4864.66977, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Amputation toe & metatarsal", "code_information": [ { "code": "28810", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 830.0, "maximum": 11798.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7838.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4909.2, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 11454.0, 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"additional_generic_notes": "" } ] }, { "description": "Amputee adapter", "code_information": [ { "code": "E0959", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 44.21, "maximum": 44.21, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Ana crown exp 1-3 per quad", "code_information": [ { "code": "D4231", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1882.11, "maximum": 2545.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 1882.1144, "standard_charge_percentage": 100.0, 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Indemnity", "plan_name": "INDEMNITY", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.464, "standard_charge_percentage": 0.6372, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial Non B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.12, "standard_charge_percentage": 0.476, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.436, "standard_charge_percentage": 0.4703, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 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"UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.45, "standard_charge_percentage": 0.4138, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.95, "standard_charge_percentage": 0.3958, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.0, "standard_charge_percentage": 0.464, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"N/A", "standard_charge_dollar": 100.0, "standard_charge_percentage": 0.4, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.75, "standard_charge_percentage": 0.391, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.0, "standard_charge_percentage": 0.328, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.5, "standard_charge_percentage": 0.35, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.25, "standard_charge_percentage": 0.409, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.0, "standard_charge_percentage": 0.7, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.25, "standard_charge_percentage": 0.317, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.5, "standard_charge_percentage": 0.31, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.25, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 0.3, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.25, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 0.3, "methodology": "percent of total billed charges" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.5, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.0, "standard_charge_percentage": 0.5, "methodology": "percent of total billed charges" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.0, "standard_charge_percentage": 0.38, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Analysis nerve", "code_information": [ { "code": "88356", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 67.7, "maximum": 180.81, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.7045, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.86025, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.666737, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.8882, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 180.81, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.7045, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.108076, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.8175, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.8882, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.1091, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.8882, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.8882, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.8882, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Analysis tumor", "code_information": [ { "code": "88358", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 66.78, "maximum": 294.49, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.385901, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.4075, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 256.9214, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 272.1625, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.4905, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.5943, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.4075, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Analyze pacemaker system", "code_information": [ { "code": "93724", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 274.98, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 373.1943, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 381.0656, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 381.0656, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 381.0656, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 373.1943, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 381.0656, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 449.657408, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 515.4035, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 476.332, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 274.98, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 381.0656, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Analyze sp inf pump w/reprog", "code_information": [ { "code": "62368", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 19.31, "maximum": 7838.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 381.0656, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 4418.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 381.0656, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 373.1943, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 381.0656, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7838.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 373.1943, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.31, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 381.0656, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 515.4035, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4810.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, 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"standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4810.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 476.332, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Anaplsma phgcytophlm amp prb", "code_information": [ { "code": "87468", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 35.09, "maximum": 53.94, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", 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"additional_generic_notes": "" } ] }, { "description": "Anca screen each antibody", "code_information": [ { "code": "86036", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 12.05, "maximum": 18.52, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.515601, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": 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"methodology": "percent of total billed charges" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.08, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "other" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 532.3796, "standard_charge_percentage": 0.4703, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 509.2868, "standard_charge_percentage": 0.4499, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Andrology infertility assmt", "code_information": [ { "code": "0255U", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 31.6, "maximum": 48.57, "gross_charge": 0.01, "discounted_cash": 0.01, 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"payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes hrna rpr lmbr&vnt&/dehs", "code_information": [ { "code": "00752", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 75.93, "maximum": 75.93, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes hrna rpr omphalocele", "code_information": [ { "code": "00754", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 88.54, "maximum": 88.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes hrna rpr upr abd nos", "code_information": [ { "code": "00750", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 50.58, "maximum": 50.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes incompl/missed ab px", "code_information": [ { "code": "01965", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 61.59, "maximum": 61.59, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.59, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes induced abortion px", "code_information": [ { "code": "01966", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 61.59, "maximum": 61.59, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.59, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes iper upr abd gstr px mo", "code_information": [ { "code": "00797", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 101.15, "maximum": 101.15, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.15, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes iper upr abd lvr trnspl", "code_information": [ { "code": "00796", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 379.53, "maximum": 379.53, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 379.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes iper upr abd nos", "code_information": [ { "code": "00790", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 88.54, "maximum": 88.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes iper upr abd pncrtect", "code_information": [ { "code": "00794", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 101.15, "maximum": 101.15, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.15, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes iper upr abd prtl hptc", "code_information": [ { "code": "00792", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 164.48, "maximum": 164.48, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes lwr intst ndsc nos", "code_information": [ { "code": "00811", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 56.04, "maximum": 56.04, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.04, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes lwr intst scr colsc", "code_information": [ { "code": "00812", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 42.03, "maximum": 42.03, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.03, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes mediascpy & dx thorscpy", "code_information": [ { "code": "00528", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 101.15, "maximum": 101.15, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.15, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes medscpy&thorscpy 1 lung", "code_information": [ { "code": "00529", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 139.12, "maximum": 139.12, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes px maj abd blood vessel", "code_information": [ { "code": "00770", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 189.84, "maximum": 189.84, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes spine transthor w/vent", "code_information": [ { "code": "00626", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 189.84, "maximum": 189.84, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes spine tranthor w/o vent", "code_information": [ { "code": "00625", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 164.48, "maximum": 164.48, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes ther interven rad artrl", "code_information": [ { "code": "01924", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 63.33, "maximum": 63.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes ther interven rad card", "code_information": [ { "code": "01925", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 88.54, "maximum": 88.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes ther interven rad tips", "code_information": [ { "code": "01931", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 88.54, "maximum": 88.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes ther interven rad vein", "code_information": [ { "code": "01930", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 63.33, "maximum": 63.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes tx interv rad cran vein", "code_information": [ { "code": "01933", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 88.54, "maximum": 88.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes tx interv rad hrt/cran", "code_information": [ { "code": "01926", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 101.15, "maximum": 101.15, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.15, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes tx interv rad th vein", "code_information": [ { "code": "01932", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 75.93, "maximum": 75.93, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes upr gi ndsc px ercp", "code_information": [ { "code": "00732", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 84.06, "maximum": 84.06, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes upr gi ndsc px nos", "code_information": [ { "code": "00731", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 70.05, "maximum": 70.05, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes upr lwr gi ndsc px", "code_information": [ { "code": "00813", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 70.05, "maximum": 70.05, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes urgent hysterectomy", "code_information": [ { "code": "01962", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 101.17, "maximum": 101.17, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes vaginal delivery only", "code_information": [ { "code": "01960", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 77.11, "maximum": 77.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes xtrnl cephalic version", "code_information": [ { "code": "01958", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 77.11, "maximum": 77.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anes/analg cs dlvr neuraxial", "code_information": [ { "code": "01968", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 30.88, "maximum": 30.88, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth abdomen vessel surg", "code_information": [ { "code": "00880", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 189.84, "maximum": 189.84, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth abdominal wall surg", "code_information": [ { "code": "00700", "type": "HCPCS" }, { "code": "00730", "type": "HCPCS" }, { "code": "00800", "type": "HCPCS" }, { "code": "00820", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 37.97, "maximum": 63.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth achilles tendon surg", "code_information": [ { "code": "01472", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 63.33, "maximum": 63.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth amniocentesis", "code_information": [ { "code": "00842", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 61.59, "maximum": 61.59, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.59, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth amputation at knee", "code_information": [ { "code": "01404", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 63.33, "maximum": 63.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth amputation at pelvis", "code_information": [ { "code": "01140", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 189.84, "maximum": 189.84, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth amputation of femur", "code_information": [ { "code": "01232", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 63.33, "maximum": 63.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth amputation of penis", "code_information": [ { "code": "00932", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 50.58, "maximum": 50.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth ankle replacement", "code_information": [ { "code": "01486", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 88.54, "maximum": 88.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth ankle/ft arthroscopy", "code_information": [ { "code": "01464", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 37.97, "maximum": 37.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth anorectal surgery", "code_information": [ { "code": "00902", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 50.58, "maximum": 50.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth arm-leg vessel surg", "code_information": [ { "code": "01656", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 126.51, "maximum": 126.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": 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"type": "HCPCS" } ], "standard_charges": [ { "minimum": 75.93, "maximum": 75.93, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth correct heart rhythm", "code_information": [ { "code": "00410", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 50.58, "maximum": 50.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth cranial surg 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] }, { "description": "Anesth dx elbow arthroscopy", "code_information": [ { "code": "01732", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 37.97, "maximum": 37.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth dx knee arthroscopy", "code_information": [ { "code": "01382", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 37.97, "maximum": 37.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth dx wrist arthroscopy", "code_information": [ { "code": "01829", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 37.97, "maximum": 37.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth ear exam", "code_information": [ { "code": "00124", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 50.58, "maximum": 50.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth ear surgery", "code_information": [ { "code": "00120", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 63.33, "maximum": 63.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth elbow area surgery", "code_information": [ { "code": "01710", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 37.97, "maximum": 37.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth elbow replacement", "code_information": [ { "code": "01760", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 88.54, "maximum": 88.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth electroshock", "code_information": [ { "code": "00104", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 50.58, "maximum": 50.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": 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"MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth face/skull bone surg", "code_information": [ { "code": "00190", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 63.33, "maximum": 63.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth facial bone surgery", "code_information": [ { "code": "00192", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 88.54, "maximum": 88.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth fat layer removal", "code_information": [ { "code": "00802", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 63.33, "maximum": 63.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth femoral artery surg", "code_information": [ { "code": "01272", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 50.58, "maximum": 50.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth femoral embolectomy", "code_information": [ { "code": "01274", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 75.93, "maximum": 75.93, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth for liver biopsy", "code_information": [ { "code": "00702", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 50.58, "maximum": 50.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth forequarter amput", "code_information": [ { "code": "01636", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 189.84, "maximum": 189.84, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth fx repair pelvis", "code_information": [ { "code": "01173", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 151.87, "maximum": 151.87, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth genitalia surgery", "code_information": [ { "code": "00920", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 37.97, "maximum": 37.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth head nerve surgery", "code_information": [ { "code": "00222", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 75.93, "maximum": 75.93, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth head vessel surgery", "code_information": [ { "code": "00216", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 189.84, "maximum": 189.84, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth head/neck/ptrunk", "code_information": [ { "code": "00300", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 63.33, "maximum": 63.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth heart surg <1 yr", "code_information": [ { "code": "00561", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 316.35, "maximum": 316.35, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 316.35, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth heart surg w/arrest", "code_information": [ { "code": "00563", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 316.35, "maximum": 316.35, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 316.35, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth heart surg w/o pump", "code_information": [ { "code": "00560", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 189.84, "maximum": 189.84, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth heart/lung transplnt", "code_information": [ { "code": "00580", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 253.02, "maximum": 253.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 253.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth hernia repair < 1 yr", "code_information": [ { "code": "00834", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 63.33, "maximum": 63.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth hernia repair preemie", "code_information": [ { "code": "00836", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 75.93, "maximum": 75.93, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth hip arthroplasty", "code_information": [ { "code": "01214", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 126.51, "maximum": 126.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth hip disarticulation", "code_information": [ { "code": "01212", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 126.51, "maximum": 126.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth hip joint procedure", "code_information": [ { "code": "01200", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 50.58, "maximum": 50.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth hip joint surgery", "code_information": [ { "code": "01210", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 75.93, "maximum": 75.93, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth hrt surg w/pmp age 1+", "code_information": [ { "code": "00562", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 253.02, "maximum": 253.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 253.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth humeral lesion surg", "code_information": [ { "code": "01758", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 63.33, "maximum": 63.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth humerus repair", "code_information": [ { "code": "01744", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 63.33, "maximum": 63.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth humerus surgery", "code_information": [ { "code": "01742", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 63.33, "maximum": 63.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth hysterectomy", "code_information": [ { "code": "00846", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 101.15, "maximum": 101.15, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.15, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth hysteroscope/graph", "code_information": [ { "code": "00952", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 50.58, "maximum": 50.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth insert penis device", "code_information": [ { "code": "00938", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 50.58, "maximum": 50.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth intrcrn nerve", "code_information": [ { "code": "00220", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 126.51, "maximum": 126.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth iridectomy", "code_information": [ { "code": "00147", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 50.58, "maximum": 50.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth kidney stone destruct", "code_information": [ { "code": "00872", "type": "HCPCS" }, { "code": "00873", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 88.54, "maximum": 88.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth kidney transplant", "code_information": [ { "code": "00868", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 126.51, "maximum": 126.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth kidney/ureter surg", "code_information": [ { "code": "00862", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 88.54, "maximum": 88.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth knee area procedure", "code_information": [ { "code": "01340", "type": "HCPCS" }, { "code": "01390", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 37.97, "maximum": 50.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth knee area surgery", "code_information": [ { "code": "01320", "type": "HCPCS" }, { "code": "01360", "type": "HCPCS" }, { "code": "01392", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 50.58, "maximum": 63.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth knee arteries surg", "code_information": [ { "code": "01440", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 63.33, "maximum": 63.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth knee artery repair", "code_information": [ { "code": "01444", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 101.15, "maximum": 101.15, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.15, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth knee artery surg", "code_information": [ { "code": "01442", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 101.15, "maximum": 101.15, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.15, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth knee arthroplasty", "code_information": [ { "code": "01402", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 88.54, "maximum": 88.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth knee joint casting", "code_information": [ { "code": "01420", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 37.97, "maximum": 37.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth knee joint procedure", "code_information": [ { "code": "01380", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 37.97, "maximum": 37.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth knee joint surgery", "code_information": [ { "code": "01400", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 50.58, "maximum": 50.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth knee veins surgery", "code_information": [ { "code": "01430", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 37.97, "maximum": 37.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth knee vessel surg", "code_information": [ { "code": "01432", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 75.93, "maximum": 75.93, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth larynx/trach < 1 yr", "code_information": [ { "code": "00326", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 101.15, "maximum": 101.15, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.15, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth leg arteries surg", "code_information": [ { "code": "01500", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 101.15, "maximum": 101.15, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.15, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth lens surgery", "code_information": [ { "code": "00142", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 75.93, "maximum": 75.93, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth lower arm casting", "code_information": [ { "code": "01860", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 37.97, "maximum": 37.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth lower arm procedure", "code_information": [ { "code": "01820", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 37.97, "maximum": 37.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth lower arm surgery", "code_information": [ { "code": "01810", "type": "HCPCS" }, { "code": "01830", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 37.97, "maximum": 37.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth lower arm vein surg", "code_information": [ { "code": "01850", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 37.97, "maximum": 37.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth lower leg bone surg", "code_information": [ { "code": "01480", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 37.97, "maximum": 37.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth lower leg casting", "code_information": [ { "code": "01490", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 37.97, "maximum": 37.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth lower leg procedure", "code_information": [ { "code": "01462", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 37.97, "maximum": 37.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth lower leg revision", "code_information": [ { "code": "01484", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 50.58, "maximum": 50.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth lower leg surgery", "code_information": [ { "code": "01470", "type": "HCPCS" }, { "code": "01474", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 37.97, "maximum": 63.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth lower leg vein surg", "code_information": [ { "code": "01520", "type": "HCPCS" }, { "code": "01522", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 37.97, "maximum": 63.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth lumbar puncture", "code_information": [ { "code": "00635", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 50.58, "maximum": 50.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth lung chest wall surg", "code_information": [ { "code": "00546", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 189.84, "maximum": 189.84, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth lwr arm artery surg", "code_information": [ { "code": "01840", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 75.93, "maximum": 75.93, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth lwr arm embolectomy", "code_information": [ { "code": "01842", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 75.93, "maximum": 75.93, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth lwr arm vein repair", "code_information": [ { "code": "01852", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 50.58, "maximum": 50.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth lwr leg embolectomy", "code_information": [ { "code": "01502", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 75.93, "maximum": 75.93, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth major vein ligation", "code_information": [ { "code": "00882", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 126.51, "maximum": 126.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth n block/inj prone", "code_information": [ { "code": "01992", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 63.33, "maximum": 63.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth neck organ 1yr/>", "code_information": [ { "code": "00320", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 75.93, "maximum": 75.93, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth neck vessel surgery", "code_information": [ { "code": "00350", "type": "HCPCS" }, { "code": "00352", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 63.33, "maximum": 126.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth nerve block/inj", "code_information": [ { "code": "01991", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 37.97, "maximum": 37.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth nose/sinus surgery", "code_information": [ { "code": "00160", "type": "HCPCS" }, { "code": "00162", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 63.33, "maximum": 88.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth one lung ventilation", "code_information": [ { "code": "00541", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 189.84, "maximum": 189.84, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth pacemaker insertion", "code_information": [ { "code": "00530", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 50.58, "maximum": 50.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth pelvic organ surg", "code_information": [ { "code": "00848", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 101.15, "maximum": 101.15, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.15, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth pelvic tumor surgery", "code_information": [ { "code": "01150", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 101.15, "maximum": 101.15, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.15, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth pelvis procedure", "code_information": [ { "code": "01160", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 50.58, "maximum": 50.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth pelvis surgery", "code_information": [ { "code": "00844", "type": "HCPCS" }, { "code": "01120", "type": "HCPCS" }, { "code": "01170", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 75.93, "maximum": 101.15, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.93, "standard_charge_percentage": 100.0, "methodology": "fee 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"Per Service Unit Rate" } ] }, { "description": "Anesth perineal surgery", "code_information": [ { "code": "00904", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 88.54, "maximum": 88.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth pharyngeal surgery", "code_information": [ { "code": "00174", "type": "HCPCS" }, { "code": "00176", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 75.93, "maximum": 88.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth procedure on femur", "code_information": [ { "code": "01220", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 50.58, "maximum": 50.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth procedure on mouth", "code_information": [ { "code": "00170", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 63.33, "maximum": 63.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth procedures on eye", "code_information": [ { "code": "00140", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 63.33, "maximum": 63.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth radical femur surg", "code_information": [ { "code": "01234", "type": "HCPCS" } ], 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"code_information": [ { "code": "01482", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 50.58, "maximum": 50.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth removal of adrenal", "code_information": [ { "code": "00866", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 126.51, "maximum": 126.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, 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"additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth removal of prostate", "code_information": [ { "code": "00865", "type": "HCPCS" }, { "code": "00908", "type": "HCPCS" }, { "code": "00914", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 63.33, "maximum": 88.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth removal of rib", "code_information": [ { "code": "00470", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 75.93, "maximum": 75.93, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth removal of testis", "code_information": [ { "code": "00926", "type": "HCPCS" }, { "code": "00928", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 50.58, "maximum": 75.93, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth removal of vulva", "code_information": [ { "code": "00906", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 50.58, "maximum": 50.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth repair of cervix", "code_information": [ { "code": "00948", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 61.59, "maximum": 61.59, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.59, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth repair of cleft lip", "code_information": [ { "code": "00102", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 75.93, "maximum": 75.93, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth repair of hernia", "code_information": [ { "code": "00830", "type": "HCPCS" }, { "code": "00832", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 50.58, "maximum": 75.93, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth revise hip repair", "code_information": [ { "code": "01215", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 126.51, "maximum": 126.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth salivary gland", "code_information": [ { "code": "00100", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 63.33, "maximum": 63.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth shoulder artery surg", "code_information": [ { "code": "01650", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 75.93, "maximum": 75.93, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": 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"outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth shoulder procedure", "code_information": [ { "code": "01620", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 50.58, "maximum": 50.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth shoulder replacement", "code_information": [ { "code": "01638", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 126.51, "maximum": 126.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth shoulder vein surg", "code_information": [ { "code": "01670", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 50.58, "maximum": 50.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth shoulder vessel surg", "code_information": [ { "code": "01652", "type": "HCPCS" }, { "code": "01654", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 101.15, "maximum": 126.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.15, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth sitting procedure", "code_information": [ { "code": "00604", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 164.48, "maximum": 164.48, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth skin ext/per/atrunk", "code_information": [ { "code": "00400", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 37.97, "maximum": 37.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth skull drainage", "code_information": [ { "code": "00212", "type": "HCPCS" }, { "code": "00214", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 63.33, "maximum": 113.9, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth skull repair/fract", "code_information": [ { "code": "00215", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 113.9, "maximum": 113.9, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth 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"methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth vaginal endoscopy", "code_information": [ { "code": "00950", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 63.33, "maximum": 63.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anesth vaginal hysterectomy", "code_information": [ { "code": "00944", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 75.93, "maximum": 75.93, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 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"standard_charge_dollar": 4418.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3588.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 4039.9108, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4039.9108, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3906.1803, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 4039.9108, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Anterior asis pad", "code_information": [ { "code": "L1250", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 38.06, "maximum": 38.06, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anterior colporrhaphy", "code_information": [ { "code": "57240", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1334.0, "maximum": 21589.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of 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"payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 17828.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 6272.2534, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8265.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 6272.2534, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 7887.09, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 6272.2534, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6214.5714, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 20960.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6214.5714, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", 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8265.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7840.31675, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10505.76, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Anterior swing band", "code_information": [ { "code": "L2335", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 147.53, "maximum": 147.53, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], 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"standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anthrax vaccine sc or im", "code_information": [ { "code": "90581", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 296.6, "maximum": 296.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 296.604, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Anti-inhibitor", "code_information": [ { "code": "J7198", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 2.27, "maximum": 6.31, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": 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"description": "Anti-Itch 0.5%-0.5% Lotion", "drug_information": { "unit": "1.000000", "type": "EA" }, "code_information": [ { "code": "00536126812", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 112.1, "gross_charge": 118.0, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.9, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.3, "standard_charge_percentage": 0.35, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.1, "standard_charge_percentage": 0.95, "estimated_amount": 999999999.0, "methodology": "percent of total billed 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"methodology": "percent of total billed charges" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.78, "standard_charge_percentage": 0.21, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.91, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.4, "standard_charge_percentage": 0.3, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.2, "standard_charge_percentage": 0.4, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.406, "standard_charge_percentage": 0.317, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.58, "standard_charge_percentage": 0.31, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.262, "standard_charge_percentage": 0.409, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.6, "standard_charge_percentage": 0.7, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial Non B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.168, "standard_charge_percentage": 0.476, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.78, "standard_charge_percentage": 0.21, "methodology": "percent of total billed charges" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.8284, "standard_charge_percentage": 0.4138, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.7044, "standard_charge_percentage": 0.3958, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.752, "standard_charge_percentage": 0.464, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.448, "standard_charge_percentage": 0.436, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.784, "standard_charge_percentage": 0.388, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.114, "standard_charge_percentage": 0.323, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.91, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.4, "standard_charge_percentage": 0.3, "methodology": "percent of total billed charges" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.0, "standard_charge_percentage": 0.5, "methodology": "percent of total billed charges" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.84, "standard_charge_percentage": 0.38, "methodology": "percent of total billed charges" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.448, "standard_charge_percentage": 0.436, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.2178, "standard_charge_percentage": 0.4171, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.1176, "standard_charge_percentage": 0.4332, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.7782, "standard_charge_percentage": 0.4049, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.1, "standard_charge_percentage": 0.95, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "per diem" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.9, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.4954, "standard_charge_percentage": 0.4703, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.0882, "standard_charge_percentage": 0.4499, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Anti-phospholipid antibody", "code_information": [ { "code": "86148", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 14.28, "maximum": 24.71, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.0945, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.711115, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Anti-reflective coating", "code_information": [ { "code": "V2750", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 15.33, "maximum": 15.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Antibody detection nos if", "code_information": [ { "code": "87299", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 10.1, "maximum": 24.76, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.758409, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield 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"methodology": "percent of total billed charges" }, { "payer_name": "Anthem Indemnity", "plan_name": "INDEMNITY", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.3828, "standard_charge_percentage": 0.6372, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.29, "standard_charge_percentage": 0.21, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.6, "standard_charge_percentage": 0.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "OPPS - Bundled" } ] }, { "description": "Anusol-Hc 25 MG Suppository", "drug_information": { "unit": "1.000000", "type": "EA" }, "code_information": [ { "code": "65649041112", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 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Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.058848, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Apheresis immunoads slctv", "code_information": [ { "code": "36516", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1710.64, "maximum": 21597.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21597.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5782.1439, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14587.34, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 20183.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 5952.977, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 20962.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 5952.977, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 20496.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 4418.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10951.29, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1710.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 5952.977, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", 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schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 5610.51, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 27572.34905, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14211.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 23366.3975, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "App mltpln uni xtrnl fix xch", "code_information": [ { "code": "20697", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 818.94, "maximum": 12065.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 4313.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 2033.4809, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4313.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2033.4809, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue 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999999999.0, "methodology": "case rate" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2541.851125, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6539.15, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4909.2, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 2399.507462, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7978.0, 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4909.2, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 2033.4809, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4442.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10732.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "APP SKN CL SSP AGRF T/A/L EA", "code_information": [ { "code": "15016", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 6302.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 6302.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "APP SKN CL SSP AGRFT T/A/L 1", "code_information": [ { "code": "15015", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 2324.22, "maximum": 7838.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 6200.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6200.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2905.2745, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 2324.2196, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 2324.2196, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2324.2196, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 2324.2196, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7838.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 2324.2196, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 6062.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6386.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 2742.579128, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3143.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "APP SKN CLL SSP F/N/G/HF 1ST", "code_information": [ { "code": "15017", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 2324.22, "maximum": 7838.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7838.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 2324.2196, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 2324.2196, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", 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"payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6386.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 2324.2196, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 6062.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 6200.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 2742.579128, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "APP SKN CLL SSP F/N/G/HF EA", "code_information": [ { "code": "15018", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 6302.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 6302.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", 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}, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 271.168, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 1132.89, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.4459, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.488, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Application of figure eight", "code_information": [ { "code": "29049", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 66.58, "maximum": 4418.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 335.5457, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 4418.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 1132.89, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.4459, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC 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"additional_generic_notes": "" } ] }, { "description": "Application of hip casts", "code_information": [ { "code": "29325", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 139.3, "maximum": 7838.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.4459, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.4459, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 4418.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", 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"methodology": "case rate" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1244.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 456.399, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 335.5457, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 1132.89, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.4459, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 398.186162, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Application of leg cast", "code_information": [ { "code": "29450", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 69.9, "maximum": 4418.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.488, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.488, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1244.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.61, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.488, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 236.57584, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.488, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of 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schedule" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 4418.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Application of shoulder cast", "code_information": [ { "code": "29055", "type": "HCPCS" }, { "code": "29058", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 73.9, "maximum": 4418.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1244.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", 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"payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 4418.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1244.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 335.5457, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 335.5457, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.4459, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.4459, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 1132.89, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 421.807375, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Applicaton on-body injector", "code_information": [ { "code": "96377", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 58.63, "maximum": 6302.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.287, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.6255, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.3512, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.17809, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.6255, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 6302.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.281875, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.6255, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.6255, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.3512, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.6255, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Apply finger cast", "code_information": [ { "code": "29086", "type": "HCPCS" } ], 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"methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.488, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 1132.89, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.59, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1244.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.8715, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.61, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.488, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1244.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 236.57584, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 271.168, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 4418.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1132.89, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Apply interstit radiat compl", "code_information": [ { "code": "77778", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 371.88, "maximum": 1192.31, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 895.8157, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 881.555, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 1040.2349, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 371.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 1192.307, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 734.59, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 881.555, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 881.555, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 881.555, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1101.94375, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 881.555, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 895.8157, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Apply intrcav radiat compl", "code_information": [ { "code": "77763", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 477.01, "maximum": 1192.31, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 881.555, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 895.8157, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1101.94375, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 603.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 881.555, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 881.555, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 881.555, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 1040.2349, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 881.555, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 477.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 895.8157, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 1192.307, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Apply intrcav radiat interm", "code_information": [ { "code": "77762", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 350.52, "maximum": 994.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 918.755, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 350.52, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 735.004, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 735.004, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 735.4913, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 867.30472, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 735.004, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 735.004, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 735.4913, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 994.1085, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 427.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 735.004, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Apply intrcav radiat simple", "code_information": [ { "code": "77761", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 285.28, "maximum": 994.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 735.4913, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 867.30472, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 735.4913, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 735.004, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 735.004, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 994.1085, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 322.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 735.004, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 285.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 735.004, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 918.755, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 735.004, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Apply r&l pulm art bands", "code_information": [ { "code": "33620", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Apply rem fixation device", "code_information": [ { "code": "20660", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 2008.09, "maximum": 7838.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 2033.4809, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 2399.507462, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6386.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 6200.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 2033.4809, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2033.4809, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 2033.4809, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7838.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 2033.4809, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6200.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 2750.326, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2008.0943, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2008.0943, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2541.851125, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 4418.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 6062.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Apply short leg cast", "code_information": [ { "code": "29435", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 79.22, "maximum": 4418.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.4459, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.4459, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.4459, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.4459, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1244.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1132.89, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 1132.89, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 335.5457, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 421.807375, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 4418.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 335.5457, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1244.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 398.186162, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 456.399, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.4459, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Apply srs headframe add-on", "code_information": [ { "code": "61800", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 6302.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 6302.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 4418.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Apply surf ldr radionuclide", "code_information": [ { "code": "77789", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 62.19, "maximum": 188.18, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.1307, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.174226, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.8206, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.176, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.1307, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.1307, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.1307, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 173.913375, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.19, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.8206, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.1307, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Aprotonin, 10,000 kiu", "code_information": [ { "code": "J0365", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 7.09, "maximum": 7.09, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": 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charges" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.8232, "standard_charge_percentage": 0.38, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.558, "standard_charge_percentage": 0.95, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.19988, "standard_charge_percentage": 0.317, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.9084, "standard_charge_percentage": 0.31, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Anthem Indemnity", "plan_name": "INDEMNITY", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.533008, "standard_charge_percentage": 0.6372, "methodology": "percent of total billed charges" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.038448, "standard_charge_percentage": 0.4332, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.860036, "standard_charge_percentage": 0.4049, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.902, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "UC Care", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.28124, "standard_charge_percentage": 0.391, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.65792, "standard_charge_percentage": 0.328, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.03076, "standard_charge_percentage": 0.409, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.148, "standard_charge_percentage": 0.7, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial Non B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.82064, "standard_charge_percentage": 0.476, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.902, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.656, "standard_charge_percentage": 0.4, "methodology": "percent of total billed charges" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.583292, "standard_charge_percentage": 0.4703, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.733836, "standard_charge_percentage": 0.4499, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.2018, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.492, "standard_charge_percentage": 0.3, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.32096, "standard_charge_percentage": 0.464, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.15504, "standard_charge_percentage": 0.436, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.574, "standard_charge_percentage": 0.35, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.558, "standard_charge_percentage": 0.95, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "per diem" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.15632, "standard_charge_percentage": 0.388, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.44972, "standard_charge_percentage": 0.323, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Aquaporin-4 antb cba each", "code_information": [ { "code": "86052", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 12.05, "maximum": 18.52, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.3043, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.515601, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Aquaporin-4 antb elisa", "code_information": [ { "code": "86051", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 11.53, "maximum": 17.71, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.5529, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.711603, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Aquatic therapy/exercises", "code_information": [ { "code": "97113", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 13.93, "maximum": 46.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Aqueous shunt eye w/o graft", "code_information": [ { "code": "66179", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 3260.78, "maximum": 21597.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6555.9275, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 14129.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 6555.9275, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6539.15, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4909.2, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 20496.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { 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"standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Argatroban nonesrd (auromed)", "code_information": [ { "code": "J0898", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1.27, "maximum": 10.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.7582, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { 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"methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Aripiprazole 5 MG Tablet", "drug_information": { "unit": "5.000000", "type": "ME" }, "code_information": [ { "code": "00904651006", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 384.75, "gross_charge": 405.0, "discounted_cash": 0.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.645, "standard_charge_percentage": 0.409, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 283.5, "standard_charge_percentage": 0.7, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", 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"standard_charge_percentage": 0.35, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 402.6, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.34, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 219.6, "standard_charge_percentage": 0.3, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" } ], "additional_generic_notes": "" } ] }, { "description": "Arm pad repl, each", "code_information": [ { "code": "K0019", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 15.51, "maximum": 15.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Arm supp att to wc rancho ty", "code_information": [ { "code": "E2627", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1064.58, "maximum": 1064.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1064.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": 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17383.86, "standard_charge_percentage": 0.323, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25311.546, "standard_charge_percentage": 0.4703, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24213.618, "standard_charge_percentage": 0.4499, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 24972.48, "standard_charge_percentage": 0.464, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 23465.52, "standard_charge_percentage": 0.436, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Indemnity", "plan_name": "INDEMNITY", "additional_payer_notes": "N/A", "standard_charge_dollar": 34294.104, "standard_charge_percentage": 0.6372, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 13185.9, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.357, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 13185.9, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.357, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0862, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp aor-celiac-msn-renal", "code_information": [ { "code": "35631", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6539.15, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4909.2, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 4909.2, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp aorsubcl/carot/innom", "code_information": [ { "code": "35626", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { 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8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp aortobifemoral", "code_information": [ { "code": "35646", "type": "HCPCS" } ], 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"plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp aortofemoral", "code_information": [ { "code": "35647", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": 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PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp axillary-axillary", "code_information": [ { "code": "35650", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 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4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp axillary-femoral", "code_information": [ { "code": "35621", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC HMO", 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"plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp axillary-pop-tibial", "code_information": [ { "code": "35623", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp carotid-subclavian", "code_information": [ { "code": "35606", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 7978.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7978.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp carotid-vertebral", "code_information": [ { "code": "35642", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 7978.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7978.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp common ipsi carotid", "code_information": [ { "code": "35601", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp fem-ant-post tib/prl", "code_information": [ { "code": "35566", "type": "HCPCS" }, { "code": "35666", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 7978.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7978.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp femoral-femoral", "code_information": [ { "code": "35661", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 7978.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7978.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp femoral-popliteal", "code_information": [ { "code": "35656", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 7978.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7978.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp grft aor/carot/innom", "code_information": [ { "code": "35526", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp grft aorcel/aormesen", "code_information": [ { "code": "35531", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6539.15, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4909.2, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 4909.2, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp grft aortbifemoral", "code_information": [ { "code": "35540", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp grft aortobi-iliac", "code_information": [ { "code": "35538", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp grft aortofemoral", "code_information": [ { "code": "35539", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp grft aortoiliac", "code_information": [ { "code": "35537", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp grft aortorenal", "code_information": [ { "code": "35560", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 4909.2, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4909.2, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6539.15, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp grft axill-brachial", "code_information": [ { "code": "35522", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp grft axill-femoral", "code_information": [ { "code": "35521", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp grft axill/fem/fem", "code_information": [ { "code": "35533", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp grft axillary-axilry", "code_information": [ { "code": "35518", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp grft brachial-brchl", "code_information": [ { "code": "35525", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp grft brchl-ulnr-rdl", "code_information": [ { "code": "35523", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp grft carotid-brchial", "code_information": [ { "code": "35510", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp grft carotid-vertbrl", "code_information": [ { "code": "35508", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 7978.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7978.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp grft contral carotid", "code_information": [ { "code": "35509", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp grft fem-femoral", "code_information": [ { "code": "35558", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp grft fem-popliteal", "code_information": [ { "code": "35556", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp grft hepatorenal", "code_information": [ { "code": "35535", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp grft iliofemoral", "code_information": [ { "code": "35565", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 7978.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7978.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp grft ilioiliac", "code_information": [ { "code": "35563", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp grft ipsilat carotid", "code_information": [ { "code": "35501", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp grft splenorenal", "code_information": [ { "code": "35536", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6539.15, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 4909.2, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4909.2, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp grft subclav-axilary", "code_information": [ { "code": "35516", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 7978.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7978.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp grft subclav-brchial", "code_information": [ { "code": "35512", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp grft subclav-carotid", "code_information": [ { "code": "35506", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 7978.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7978.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp grft subclav-subclav", "code_information": [ { "code": "35511", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp grft subclav-vertbrl", "code_information": [ { "code": "35515", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 7978.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7978.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp ilio-celiac", "code_information": [ { "code": "35632", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp ilio-mesenteric", "code_information": [ { "code": "35633", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp iliofemoral", "code_information": [ { "code": "35665", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 7978.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7978.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp ilioiliac", "code_information": [ { "code": "35663", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 7978.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { 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"payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp iliorenal", "code_information": [ { "code": "35634", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", 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"plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp subclav-subclavian", "code_information": [ { "code": "35612", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, 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"standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art byp subclav-vertebrl", "code_information": [ { "code": "35645", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 7978.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", 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"methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7978.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Art pressure waveform analys", "code_information": [ { "code": "93050", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 15.38, "maximum": 1509.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.117, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.117, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.71806, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.117, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.117, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.2027, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 1132.89, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.0945, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.2027, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1132.89, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.89625, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.117, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Art trnsposj carotid subclav", "code_information": [ { "code": "35695", "type": "HCPCS" } ], "standard_charges": [ { 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"payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Artacent ac 1 sq cm", "code_information": [ { "code": "Q4190", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 840.75, "maximum": 1509.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 840.7525, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 1077.7575, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Artery expos/graft artery", "code_information": [ { "code": "33987", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1132.89, "maximum": 7978.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7978.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 1132.89, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1132.89, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Artery to vein shunt", "code_information": [ { "code": "36835", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1172.0, "maximum": 21589.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 20960.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4999.016875, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 4719.07193, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 6937.62, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1172.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6785.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 3999.2135, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6785.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 5408.996, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3999.2135, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 14129.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 3999.2135, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7978.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9241.04, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3999.2135, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20960.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21589.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3982.5527, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3982.5527, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 3999.2135, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 20495.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6937.62, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Artery transpose/endovas taa", "code_information": [ { "code": "33889", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8859.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8859.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Artery x-ray each vessel", "code_information": [ { "code": "75774", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 75.52, "maximum": 75.52, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.52, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Artery x-rays adrenal gland", "code_information": [ { "code": "75731", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 112.18, "maximum": 11696.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3982.5527, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3999.2135, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 3999.2135, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 4719.07193, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 5408.996, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11696.74935, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.18, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10952.0125, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3999.2135, "standard_charge_percentage": 100.0, 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"HCPCS" } ], "standard_charges": [ { "minimum": 5610.51, "maximum": 28055.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 5610.51, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5610.51, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8859.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7473.32, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": 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"additional_generic_notes": "" } ] }, { "description": "Arthrd cmbn 1ntrspc ea addl", "code_information": [ { "code": "22634", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrd cmbn 1ntrspc lumbar", "code_information": [ { "code": "22633", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 8505.0, "maximum": 31603.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 29369.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 28717.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 9063.14, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 23366.3975, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29369.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23284.5202, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12072.28, 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"standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 26381.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10951.29, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10732.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 16348.5815, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 10951.29, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 25795.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrd hip jt sbtrchc osteot", "code_information": [ { "code": "27286", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 6937.62, "maximum": 28055.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28055.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9241.04, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": 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"payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6937.62, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrd lat xtrcvtry tq ea ad", "code_information": [ { "code": "22534", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 8505.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", 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"case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8859.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10505.76, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 19660.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7887.09, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28055.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrd pst dfrm 7-12 vrt sgm", "code_information": [ { "code": "22802", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 7887.09, "maximum": 28055.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27238.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28055.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7887.09, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", 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"standard_charge_dollar": 8859.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27238.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 27238.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6539.15, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 4909.2, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4909.2, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 26633.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrd pst tq 1ntrspc crv", "code_information": [ { "code": "22600", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 4909.2, "maximum": 28055.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4909.2, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 26633.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27238.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 19660.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28055.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 27238.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8859.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6539.15, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 4909.2, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrd pst tq 1ntrspc ea add", "code_information": [ { "code": "22614", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 14587.34, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 10951.29, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7978.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14587.34, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 6302.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10951.29, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrd pst tq 1ntrspc lm ea", "code_information": [ { "code": "22632", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1435.0, "maximum": 7978.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 6302.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.39, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.41, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7978.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrd pst tq 1ntrspc lum", "code_information": [ { "code": "22630", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 5610.51, "maximum": 31603.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 23366.3975, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 19660.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 23366.3975, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28055.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23284.5202, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 23366.3975, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 27572.34905, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 31603.422, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27238.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23366.3975, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 26633.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 5610.51, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 23366.3975, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23284.5202, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29207.996875, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7473.32, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5610.51, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 27238.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrd pst tq 1ntrspc lumbar", "code_information": [ { "code": "22612", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 8505.0, "maximum": 31603.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 19660.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26381.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 26381.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29207.996875, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10951.29, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 23366.3975, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 23366.3975, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27172.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14587.34, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23366.3975, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 25795.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 10951.29, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 27572.34905, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 31603.422, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23284.5202, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 23366.3975, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 23366.3975, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23284.5202, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 13521.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrd pst tq 1ntrspc thrc", "code_information": [ { "code": "22610", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 4909.2, "maximum": 28055.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28055.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 27238.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 4909.2, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 26633.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6539.15, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27238.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4909.2, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 19660.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrd pst tq atlas-axis", "code_information": [ { "code": "22595", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 4909.2, "maximum": 28055.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28055.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 27238.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6539.15, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 19660.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8859.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4909.2, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27238.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 4909.2, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 26633.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrd pst tq craniocervical", "code_information": [ { "code": "22590", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 5610.51, "maximum": 28055.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC HMO", 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"HCPCS" } ], "standard_charges": [ { "minimum": 10003.79, "maximum": 27172.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27172.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16443.9676, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20435.726875, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 16348.5815, "standard_charge_percentage": 100.0, "methodology": "fee 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"standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrt elbw capsl exc rls", "code_information": [ { "code": "24006", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1172.0, "maximum": 21589.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 14129.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6937.62, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4044.2119, "standard_charge_percentage": 100.0, "methodology": 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products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "As-aort grf f/aortic dsj", "code_information": [ { "code": "33858", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1132.89, "maximum": 8859.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1132.89, 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100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "As-aort grf f/ds oth/thn dsj", "code_information": [ { "code": "33859", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1132.89, "maximum": 8859.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1132.89, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8859.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": 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"additional_payer_notes": "N/A", "standard_charge_dollar": 1.45604, "standard_charge_percentage": 0.409, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.492, "standard_charge_percentage": 0.7, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.473128, "standard_charge_percentage": 0.4138, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", 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"additional_generic_notes": "" } ] }, { "description": "Aspirin-Dipyridam ER 25-200 MG", "drug_information": { "unit": "1.000000", "type": "EA" }, "code_information": [ { "code": "16714096401", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 32.91, "gross_charge": 34.64, "discounted_cash": 0.01, "setting": "inpatient", "payers_information": [ { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.10304, "standard_charge_percentage": 0.436, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.448344, "standard_charge_percentage": 0.4171, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.052, 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"methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.5912, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Assay free hydroxyproline", "code_information": [ { "code": "83500", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 20.13, "maximum": 34.81, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.5312, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", 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"setting": "outpatient", "payers_information": [ { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.39639, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.277, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.07, 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"payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.633348, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Assay iga/igd/igg/igm each", "code_information": [ { "code": "82784", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 6.08, "maximum": 14.31, 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"standard_charge_dollar": 9.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Assay lipoprotein pla2", "code_information": [ { "code": "83698", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 36.95, "maximum": 71.18, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.31, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.31, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.521, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.17747, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.31, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Assay malate dehydrogenase", "code_information": [ { "code": "83775", "type": "HCPCS" } ], "standard_charges": [ { 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"additional_payer_notes": "N/A", "standard_charge_dollar": 10.5859, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Assay myeloperoxidase", "code_information": [ { "code": "83876", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 15.13, "maximum": 78.18, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.176982, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.86, "standard_charge_percentage": 100.0, "methodology": "fee 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], "standard_charges": [ { "minimum": 8.63, "maximum": 14.92, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.921257, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", 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"HCPCS" } ], "standard_charges": [ { "minimum": 19.72, "maximum": 39.16, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.159432, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.5976, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Assay of amikacin", "code_information": [ { "code": "80150", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 13.4, "maximum": 23.17, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.658, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.17406, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.4, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Assay of androstenedione", "code_information": [ { "code": "82157", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 26.02, "maximum": 45.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.000241, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.0563, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Assay of androsterone", "code_information": [ { "code": "82160", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 22.23, "maximum": 39.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.277667, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.7081, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Assay of angiotensin ii", "code_information": [ { "code": "82163", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 18.24, "maximum": 31.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.52, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.545098, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.52, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.52, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.4814, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Assay of apolipoprotein", "code_information": [ { "code": "82172", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 13.15, "maximum": 32.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", 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"description": "Assay of cpk in blood", "code_information": [ { "code": "82552", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 11.9, "maximum": 20.57, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.57289, 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"methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.703801, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.5643, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Assay of pregnanetriol", "code_information": [ { "code": "84138", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 16.84, "maximum": 32.35, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.2328, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", 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"payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.59, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.75, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.59, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.8238, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.491466, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], 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"standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Assay of proinsulin", "code_information": [ { "code": "84206", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 19.39, "maximum": 41.03, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.027545, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.69, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.3435, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.69, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.69, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Assay of prolactin", "code_information": [ { "code": "84146", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 17.11, "maximum": 29.8, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", 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"methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.0015, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.77, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.201605, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.77, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.17, "standard_charge_percentage": 100.0, "methodology": "fee 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"standard_charge_dollar": 5.61, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.61, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.631155, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Assay of psa complexed", "code_information": [ { "code": "84152", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 16.35, "maximum": 28.26, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.4095, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.35, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.258165, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Assay of pyruvate", "code_information": [ { "code": "84210", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 11.58, "maximum": 22.25, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.7961, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.251827, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Assay of pyruvate kinase", "code_information": [ { "code": "84220", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 8.39, "maximum": 14.52, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.519258, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.5694, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Assay of quinidine", "code_information": [ { "code": "80194", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 12.98, "maximum": 22.44, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.441003, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", 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"standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.7132, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Assay of somatomedin", "code_information": [ 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"additional_generic_notes": "" } ] }, { "description": "Assay of total estradiol", "code_information": [ { "code": "82670", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 24.71, "maximum": 42.94, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.942952, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.1336, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Assay of total testosterone", "code_information": [ { "code": "84403", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 22.8, "maximum": 39.68, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.8, "standard_charge_percentage": 100.0, "methodology": "fee 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schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Assay of total thyroxine", "code_information": [ { "code": "84436", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 6.03, "maximum": 10.57, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.8787, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE 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"standard_charges": [ { "minimum": 11.01, "maximum": 19.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.3209, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.603363, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": 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"standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.4976, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Assay of tsi globulin", "code_information": 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"additional_generic_notes": "" } ] }, { "description": "Assay of vitamin b-1", "code_information": [ { "code": "84425", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 18.87, "maximum": 32.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.63286, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.498, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Assay of vitamin b-2", "code_information": [ { "code": "84252", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 17.99, "maximum": 31.12, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.24, "standard_charge_percentage": 100.0, 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schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Assay of vitamin b-6", "code_information": [ { "code": "84207", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 24.97, "maximum": 43.2, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.203069, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.3767, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Assay of vitamin e", "code_information": [ { "code": "84446", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 12.0, "maximum": 21.8, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.18, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.802534, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.18, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.18, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.3762, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Assay of vitamin k", "code_information": [ { "code": "84597", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 12.2, "maximum": 21.09, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", 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"standard_charge_dollar": 14.35, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.6193, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.35, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.75, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Assay serum cholinesterase", "code_information": [ { "code": "82480", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 7.0, "maximum": 12.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { 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"plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.45, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.2661, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Assay total hydroxyproline", "code_information": [ { "code": "83505", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 21.6, "maximum": 37.36, "gross_charge": 0.01, "discounted_cash": 0.01, 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Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.68599, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.5305, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.973, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.5305, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.5305, "standard_charge_percentage": 100.0, 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}, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.7803, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.725375, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.7803, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.7803, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 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"additional_payer_notes": "N/A", "standard_charge_dollar": 27.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.760602, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { 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"additional_payer_notes": "N/A", "standard_charge_dollar": 118.44, "standard_charge_percentage": 0.21, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 535.8, "standard_charge_percentage": 0.95, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "per diem" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 310.2, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 233.3832, "standard_charge_percentage": 0.4138, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.2312, "standard_charge_percentage": 0.3958, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.788, "standard_charge_percentage": 0.317, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.84, "standard_charge_percentage": 0.31, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.676, "standard_charge_percentage": 0.409, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 394.8, "standard_charge_percentage": 0.7, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.832, "standard_charge_percentage": 0.388, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.172, "standard_charge_percentage": 0.323, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.18, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 169.2, "standard_charge_percentage": 0.3, "methodology": "percent of total billed charges" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.0, "standard_charge_percentage": 0.5, "methodology": "percent of total billed charges" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 214.32, "standard_charge_percentage": 0.38, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.6, "standard_charge_percentage": 0.4, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.4, "standard_charge_percentage": 0.35, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Indemnity", "plan_name": "INDEMNITY", "additional_payer_notes": "N/A", "standard_charge_dollar": 359.3808, "standard_charge_percentage": 0.6372, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.18, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 169.2, "standard_charge_percentage": 0.3, "methodology": "percent of total billed charges" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.904, "standard_charge_percentage": 0.436, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.2444, "standard_charge_percentage": 0.4171, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.3248, "standard_charge_percentage": 0.4332, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 228.3636, "standard_charge_percentage": 0.4049, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 261.696, "standard_charge_percentage": 0.464, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.904, "standard_charge_percentage": 0.436, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 310.2, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Atenolol 25 MG Tablet", "drug_information": { "unit": "25.000000", "type": "ME" }, "code_information": [ { "code": "00093078701", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 125.4, "gross_charge": 132.0, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.4, "standard_charge_percentage": 0.95, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, 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"methodology": "percent of total billed charges" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" } ], "additional_generic_notes": "" } ] }, { "description": "Atropine 8 MG/20 Ml Vial", "drug_information": { "unit": "0.400000", "type": "ME" }, "code_information": [ { "code": "00641600601", "type": "NDC" }, { "code": "00641600610", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 214.9, "gross_charge": 307.0, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "UC Care", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.037, "standard_charge_percentage": 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"standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.47, "standard_charge_percentage": 0.21, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.389, "standard_charge_percentage": 0.327, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.563, "standard_charge_percentage": 0.409, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue 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"payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.47, "standard_charge_percentage": 0.21, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.85, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.1193, "standard_charge_percentage": 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"additional_generic_notes": "OPPS - Bundled" } ] }, { "description": "Atropine comp con", "code_information": [ { "code": "J7635", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1.71, "maximum": 1.71, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.7085, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.7085, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.7085, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Atropine comp unit", "code_information": [ { "code": "J7636", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1.06, "maximum": 1.06, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.0625, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.0625, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.0625, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Atropine sulfate injection", "code_information": [ { "code": "J0461", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.21, "maximum": 4.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.2295, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.214, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.2295, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.2295, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": 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"MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.0832, "standard_charge_percentage": 0.464, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.8368, "standard_charge_percentage": 0.436, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.5992, "standard_charge_percentage": 0.409, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", 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"methodology": "percent of total billed charges" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.84, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 0.4, "methodology": "percent of total billed charges" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net Commercial Non B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.1888, "standard_charge_percentage": 0.476, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.13864, "standard_charge_percentage": 0.4703, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.95912, "standard_charge_percentage": 0.4499, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.84, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4408, "standard_charge_percentage": 0.391, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.8864, "standard_charge_percentage": 0.328, "methodology": "percent 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"payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.7981, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.1063, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.1667, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.7981, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.8711, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Audiometry air only", "code_information": [ { "code": "0208T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 49.87, "maximum": 67.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.1063, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.8711, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.4595, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.338875, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.8711, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.8711, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.847898, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.1063, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.8711, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.8711, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Audit/dast 15-30 min", "code_information": [ { "code": "99408", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 31.24, "maximum": 31.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Audit/dast over 30 min", "code_information": [ { "code": "99409", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 59.61, "maximum": 59.61, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.61, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Auditory function + 15 min", "code_information": [ { "code": "92621", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 10.11, "maximum": 10.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Auditory function 60 min", "code_information": [ { "code": "92620", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 40.75, "maximum": 268.87, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.7981, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.7981, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 234.581758, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": 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}, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.1667, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.7981, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.869, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Augmentation cheek bone", "code_information": [ { "code": "21270", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1334.0, "maximum": 21597.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 20962.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20962.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10505.76, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 8869.396368, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 10166.102, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 17828.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8265.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9395.547, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8505.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7887.09, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 7887.09, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1334.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7516.4376, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7316.8969, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 7516.4376, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 7516.4376, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8265.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 20496.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 7516.4376, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21597.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7316.8969, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 7516.4376, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Augmentation lower jaw bone", "code_information": [ { "code": "21125", "type": "HCPCS" }, { "code": "21127", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1851.0, "maximum": 21597.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1851.0, "standard_charge_percentage": 100.0, "methodology": 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"methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 12065.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 9076.8233, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27172.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8938.5262, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 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"standard_charge_dollar": 9076.8233, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 10710.651494, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 9076.8233, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 12276.546, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Autoimmune ra alys 12 bmrk", "code_information": [ { "code": "81490", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 840.65, "maximum": 1292.12, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": 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100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "AUTOINFLAM DS VEXAS SYND DNA", "code_information": [ { "code": "0500U", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 175.4, "maximum": 175.4, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.4, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Autol cell implt adps hrvg", "code_information": [ { "code": "0565T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1244.0, "maximum": 12065.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1244.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6937.62, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1244.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9241.04, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7978.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 6937.62, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 12065.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Autol cell implt adps njx", "code_information": [ { "code": "0566T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1132.89, "maximum": 7978.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3588.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 6302.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7978.0, "standard_charge_percentage": 100.0, "methodology": 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100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Autologous blood op salvage", "code_information": [ { "code": "86891", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 5.81, "maximum": 1403.85, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1037.9531, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 1037.9531, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.8123, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", 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"payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 73581.813, "standard_charge_percentage": 0.95, "estimated_amount": 999999999.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC", "code_information": [ { "code": "017", "type": "MS-DRG" }, { "code": "17", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 92710.22, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 73581.813, "standard_charge_percentage": 0.95, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 57500.86, "standard_charge_percentage": 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"standard_charges": [ { "minimum": 2.26, "maximum": 3.9, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.26, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.901755, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": 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"methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.634812, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Automated reticulocyte count", "code_information": [ { "code": "85045", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 3.55, "maximum": 6.12, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.99, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.99, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.7239, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": 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"standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.7803, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.6032, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.7803, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.725375, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": 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"MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.7981, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.7981, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.7981, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 234.581758, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.869, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.1667, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Autonomic nrv syst funj test", "code_information": [ { "code": "95923", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 159.6, "maximum": 221.52, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.7803, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.7803, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE 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"additional_payer_notes": "N/A", "standard_charge_dollar": 5610.51, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "AV fistula or graft arterial", "code_information": [ { "code": "G0392", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 2491.0, "maximum": 2491.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 2491.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "AV fistula or graft venous", "code_information": [ { "code": "G0393", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 2491.0, "maximum": 2491.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 2491.0, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Av fistula revision", "code_information": [ { "code": "36833", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1172.0, "maximum": 27172.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 25795.0, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 8104.809232, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 9289.7365, 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"standard_charge_dollar": 6937.62, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 14129.0, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8585.603, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 6868.4824, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6868.4824, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of 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"additional_payer_notes": "N/A", "standard_charge_dollar": 5610.51, "standard_charge_percentage": 100.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Avapro 150 MG Tablet", "drug_information": { "unit": "150.000000", "type": "ME" }, "code_information": [ { "code": "00024585130", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 44.1, "gross_charge": 46.42, "discounted_cash": 0.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.71514, "standard_charge_percentage": 0.317, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.3902, "standard_charge_percentage": 0.31, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", 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"standard_charge_dollar": 243.95, "standard_charge_percentage": 0.35, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" } ], "additional_generic_notes": "" } ] }, { "description": "Azactam 2 Gm Vial", "drug_information": { "unit": "2.000000", "type": "GR" }, "code_information": [ { "code": "00003257016", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 885.5, "gross_charge": 1265.0, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 265.65, "standard_charge_percentage": 0.21, "methodology": "percent of total billed charges" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 547.998, "standard_charge_percentage": 0.4332, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 512.1985, "standard_charge_percentage": 0.4049, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial Non B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 602.14, "standard_charge_percentage": 0.476, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", 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total billed charges" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.97303, "standard_charge_percentage": 0.4138, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.36473, "standard_charge_percentage": 0.3958, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" } ], "additional_generic_notes": "" } ] }, { "description": "Azathioprine oral 50mg", "code_information": [ { "code": "J7500", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 3.49, "maximum": 4.9, "gross_charge": 0.01, 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ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 307.1294, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "B1 str & fx rsk vrt fx assmt", "code_information": [ { "code": "0743T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 307.13, "maximum": 415.4, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 383.91175, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 307.1294, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 362.412692, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 415.397, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 307.1294, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 307.1294, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 307.1294, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 307.1294, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "B1 str&fx rsk transmis data", "code_information": [ { "code": "0555T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 31.12, "maximum": 109.26, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.89625, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.117, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.117, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.117, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.2027, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.0945, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.117, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.2564, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.2027, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.117, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.71806, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Babesia microti amp prb", "code_information": [ { "code": "87469", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 35.09, "maximum": 53.94, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.4101, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.938807, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Bacitracin 50 000 Unit Vial", "drug_information": { "unit": "50000.000000", "type": "UN" }, "code_information": [ { "code": "63323032931", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 1410.75, "gross_charge": 1485.0, "discounted_cash": 0.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 607.365, "standard_charge_percentage": 0.409, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1039.5, "standard_charge_percentage": 0.7, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Indemnity", "plan_name": "INDEMNITY", "additional_payer_notes": "N/A", "standard_charge_dollar": 946.242, "standard_charge_percentage": 0.6372, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.04, "standard_charge_percentage": 0.464, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 647.46, "standard_charge_percentage": 0.436, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 363.825, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 445.5, "standard_charge_percentage": 0.3, "methodology": "percent of total billed charges" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 742.5, "standard_charge_percentage": 0.5, "methodology": "percent of total billed charges" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 564.3, "standard_charge_percentage": 0.38, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1410.75, "standard_charge_percentage": 0.95, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "per diem" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 816.75, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "UC Care", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 580.635, "standard_charge_percentage": 0.391, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 487.08, "standard_charge_percentage": 0.328, "methodology": "percent of total billed charges" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 647.46, "standard_charge_percentage": 0.436, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 619.3935, "standard_charge_percentage": 0.4171, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 816.75, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1410.75, "standard_charge_percentage": 0.95, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "per diem" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 594.0, "standard_charge_percentage": 0.4, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 576.18, "standard_charge_percentage": 0.388, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 479.655, "standard_charge_percentage": 0.323, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.745, "standard_charge_percentage": 0.317, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 460.35, "standard_charge_percentage": 0.31, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 519.75, "standard_charge_percentage": 0.35, 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Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 614.493, "standard_charge_percentage": 0.4138, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 587.763, "standard_charge_percentage": 0.3958, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.302, "standard_charge_percentage": 0.4332, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 601.2765, "standard_charge_percentage": 0.4049, "estimated_amount": 999999999.0, "methodology": "percent of total billed 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"standard_charge_percentage": 0.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bacitracin Zn 500 Unit/Gm Oint", "drug_information": { "unit": "1.000000", "type": "EA" }, "code_information": [ { "code": "14428000888", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 14.12, "gross_charge": 14.86, "discounted_cash": 0.01, "setting": "inpatient", "payers_information": [ { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.988658, "standard_charge_percentage": 0.4703, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.685514, "standard_charge_percentage": 0.4499, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Regal Senior", "plan_name": "HMO", 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"percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC", "code_information": [ { "code": "519", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 44132.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "inpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 0.388, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 19035.97, "standard_charge_percentage": 1.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17292.0, "standard_charge_percentage": 100.0, 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100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8777.03, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 13937.29, "standard_charge_percentage": 1.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 16446.0022, "standard_charge_percentage": 1.18, "estimated_amount": 999999999.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Back upholstery, replacement", "code_information": [ { "code": "E0982", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 41.9, "maximum": 41.9, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": 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Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.0265, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.1009, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { 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"10.000000", "type": "ME" }, "code_information": [ { "code": "00172409660", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 13.51, "gross_charge": 14.22, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.19992, "standard_charge_percentage": 0.436, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.931162, "standard_charge_percentage": 0.4171, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial Non B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.76872, "standard_charge_percentage": 0.476, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.884236, "standard_charge_percentage": 0.4138, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.628276, "standard_charge_percentage": 0.3958, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.821, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.688, "standard_charge_percentage": 0.4, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.9862, "standard_charge_percentage": 0.21, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.821, "standard_charge_percentage": 0.55, "methodology": "percent of total 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999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 44480.1875, "standard_charge_percentage": 0.95, "estimated_amount": 999999999.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC", "code_information": [ { "code": "96", "type": "MS-DRG" }, { "code": "096", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 36820.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "inpatient", "payers_information": [ { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28826.675, "standard_charge_percentage": 1.25, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 23061.34, "standard_charge_percentage": 1.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 23061.34, "standard_charge_percentage": 1.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 23061.34, "standard_charge_percentage": 1.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21040.296316, "standard_charge_percentage": 100.0, "methodology": "case rate" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8777.03, 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Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23061.34, "standard_charge_percentage": 1.0, "estimated_amount": 999999999.0, "methodology": "case rate" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 0.388, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Indemnity", "plan_name": "INDEMNITY", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 0.6372, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 29223.5295, "standard_charge_percentage": 0.95, "estimated_amount": 999999999.0, "methodology": "case rate" } ], "additional_generic_notes": "" } ] }, { "description": "Bactericidal level serum", "code_information": [ { "code": "87197", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 13.36, "maximum": 23.08, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.5696, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.36, 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"Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.084256, "standard_charge_percentage": 0.4138, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.776096, "standard_charge_percentage": 0.3958, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.1944, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", 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7.94368, "standard_charge_percentage": 0.464, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.46432, "standard_charge_percentage": 0.436, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial Non B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.14912, "standard_charge_percentage": 0.476, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.992, "standard_charge_percentage": 0.35, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.64256, "standard_charge_percentage": 0.388, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.52976, "standard_charge_percentage": 0.323, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.5952, "standard_charge_percentage": 0.21, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.1944, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.136, "standard_charge_percentage": 0.3, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.416384, "standard_charge_percentage": 0.4332, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC National", "plan_name": "NATIONAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.931888, "standard_charge_percentage": 0.4049, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.264, 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"standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.008, "standard_charge_percentage": 0.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Barrera slor dl per sq cm", "code_information": [ { "code": "Q4281", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 3398.32, "maximum": 3398.32, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3398.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Bartonella antibody", "code_information": [ { "code": "86611", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 9.05, "maximum": 15.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.18, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.18, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.654314, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.18, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", 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"standard_charges": [ { "minimum": 38.08, "maximum": 65.86, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.856895, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.5485, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", 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{ "code": "92540", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 82.13, "maximum": 268.87, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.7981, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.7981, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.7981, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.13, 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"standard_charge_dollar": 248.497625, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.7981, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 234.581758, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Basiliximab", "code_information": [ { "code": "J0480", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 4398.0, "maximum": 12254.76, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4581.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal", "plan_name": "All products/POS", "additional_payer_notes": "N/A", "standard_charge_dollar": 4487.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4588.77, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4476.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5735.9625, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4650.35, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4650.35, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 5414.7486, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 4650.35, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 5956.1408, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 4398.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 4588.77, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 5956.1408, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12254.7635, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 4453.277, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 4588.77, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Bath tub wall rail", "code_information": [ { "code": "E0241", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 14.62, "maximum": 14.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Battery charger, dual mode", "code_information": [ { "code": "E2367", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 263.62, "maximum": 263.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 263.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Battery charger, single mode", "code_information": [ { "code": "E2366", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 212.64, "maximum": 212.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Battery chrgr 12 volt utah/e", "code_information": [ { "code": "L7366", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 280.0, "maximum": 280.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 280.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Battery chrgr six volt otto", "code_information": [ { "code": "L7362", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 116.81, "maximum": 116.81, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.81, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Battery elec/combo vad, rep", "code_information": [ { "code": "Q0496", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1062.02, "maximum": 1062.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1062.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Bayer Aspirin 325 MG Tablet", "drug_information": { "unit": "325.000000", "type": "ME" }, "code_information": [ { "code": "12843010110", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 3.38, "gross_charge": 3.56, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.958, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.473128, "standard_charge_percentage": 0.4138, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC Select_Select Plus", "plan_name": "SELECT_SELECT PLUS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.409048, "standard_charge_percentage": 0.3958, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Anthem Indemnity", "plan_name": "INDEMNITY", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.268432, "standard_charge_percentage": 0.6372, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.38128, "standard_charge_percentage": 0.388, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14988, "standard_charge_percentage": 0.323, "methodology": "percent of total billed charges" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.7476, "standard_charge_percentage": 0.21, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8722, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.068, "standard_charge_percentage": 0.3, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8722, "standard_charge_percentage": 0.245, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.068, "standard_charge_percentage": 0.3, "methodology": "percent of total billed charges" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.382, "standard_charge_percentage": 0.95, "estimated_amount": 999999999.0, "methodology": "percent of total 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"standard_charge_percentage": 0.4499, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bayer Aspirin EC 325 MG Tablet", "drug_information": { "unit": "325.000000", "type": "ME" }, "code_information": [ { "code": "00280211010", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 3.96, "gross_charge": 4.17, "discounted_cash": 0.01, "setting": "inpatient", "payers_information": [ { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.81812, "standard_charge_percentage": 0.436, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.739307, "standard_charge_percentage": 0.4171, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem 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"standard_charge_percentage": 0.4, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.93488, "standard_charge_percentage": 0.464, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net Commercial B&G", "plan_name": "All PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.81812, "standard_charge_percentage": 0.436, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.70553, "standard_charge_percentage": 0.409, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "ALL PRODUCTS", "additional_payer_notes": "N/A", "standard_charge_dollar": 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"additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "estimated_amount": 999999999.0, "methodology": "per diem" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.2935, "standard_charge_percentage": 0.55, "methodology": "percent of total billed charges" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.961151, "standard_charge_percentage": 0.4703, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "UHC PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.876083, "standard_charge_percentage": 0.4499, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bcat1&ikzf1 prmtr mthyln aly", "code_information": [ { "code": "0229U", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 384.0, "maximum": 590.23, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 590.22912, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 551.616, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Bcg live intravesical 1mg", "code_information": [ { "code": "J9030", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 2.92, "maximum": 7.68, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.92, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 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"additional_payer_notes": "N/A", "standard_charge_dollar": 161.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Bckdhb gene", "code_information": [ { "code": "81205", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 94.99, "maximum": 146.0, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.99, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.996578, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.4454, 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"additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Bcr/abl1 gene major bp quan", "code_information": [ { "code": "0040U", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 327.92, "maximum": 630.05, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 409.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 409.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 588.8324, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 327.92, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 630.050668, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 409.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Bcr/abl1 gene minor bp", "code_information": [ { "code": "81207", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 72.3, "maximum": 222.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 208.0715, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.636505, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Bcr/abl1 gene other bp", "code_information": [ { "code": "81208", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 120.14, "maximum": 329.88, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 214.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.295, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 214.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 329.87565, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 214.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Bdy surf mapg pm/cvdfb f/up", "code_information": [ { "code": "0696T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 47.12, "maximum": 64.09, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.1164, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.3807, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.1164, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Medicare_DSNP", "plan_name": "MEDICARE ADVANTAGE_DSNP", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.3807, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.909226, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Workers Comp", "plan_name": "WORKERS COMP", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.087, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare Advantage", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.3807, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.3807, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "LA Care Commercial", "plan_name": "Covered CA", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.225875, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare", "plan_name": "MEDICARE ADVANTAGE", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.3807, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Bebtelovimab 175 mg", "code_information": [ { "code": "Q0222", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 2142.0, "maximum": 5729.85, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2394.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Cigna HMO", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5729.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2142.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Regal Senior", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2394.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 2142.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2142.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Bebtelovimab injection", "code_information": [ { "code": "M0222", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 445.35, "maximum": 556.68, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Commercial", "plan_name": "PASC", "additional_payer_notes": "N/A", "standard_charge_dollar": 525.507454, "standard_charge_percentage": 100.0, 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"standard_charge_dollar": 874.331625, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Becaplermin gel 1%, 0.5 gm", "code_information": [ { "code": "S0157", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 46.23, "maximum": 123.67, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield of California", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.2315, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "IFP", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.2315, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield of California", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.2315, "standard_charge_percentage": 100.0, 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Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.35, "standard_charge_percentage": 0.35, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bed safety enclosure", "code_information": [ { "code": "E0316", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 1950.43, "maximum": 1950.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "LA Care Medi-Cal", "plan_name": "MEDI-CAL", "additional_payer_notes": "N/A", "standard_charge_dollar": 1950.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Service Unit Rate" } ] }, { "description": "Behav chng smoking > 10 min", "code_information": [ { "code": "99407", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 19.93, "maximum": 51.2, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { 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