{ "hospital_name": "Resnick Neuropsychiatric Hospital at UCLA", "last_updated_on": "2025-03-29", "as_of_date": "2025-01-01", "version": "2.0.0", "hospital_location": [ "Resnick Neuropsychiatric Hospital at UCLA" ], "hospital_address": [ "150 UCLA Medical Plaza, Los Angeles, CA 90095" ], "license_information": { "license_number": "930000153|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": "0.9% SODIUM CHLORIDE--CONTROL FOR ATG", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "63323018610", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ABACAVIR SULFATE 20 MG/ML PO SOLN", "drug_information": { "unit": "240.000000", "type": "UN" }, "code_information": [ { "code": "64980040524", "type": "NDC" } ], "standard_charges": [ { "minimum": 61.45, "maximum": 204.97, "gross_charge": 218.05, "discounted_cash": 119.93, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.45, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.66, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 185.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.27, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 173.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ABACAVIR SULFATE 300 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084002121", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.55, "maximum": 8.51, "gross_charge": 9.05, "discounted_cash": 4.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.63, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.34, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.19, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.09, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ABACAVIR SULFATE-LAMIVUDINE 600-300 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "65862033530", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ABACAVIR-DOLUTEGRAVIR-LAMIVUD 600-50-300 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "49702023113", "type": "NDC" } ], "standard_charges": [ { "minimum": 119.51, "maximum": 398.65, "gross_charge": 424.1, "discounted_cash": 233.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 339.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 359.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.41, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.57, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 253.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 398.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 373.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.51, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 360.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 318.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 288.39, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 398.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 332.07, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 318.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 373.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ABATACEPT 125 MG/ML SC SOSY", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00003218811", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.72, "maximum": 3636.54, "gross_charge": 3868.66, "discounted_cash": 2127.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2243.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3094.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3276.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1125.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1856.96, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2317.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2313.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3636.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3404.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1090.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3288.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2901.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1362.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2630.69, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3636.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3029.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3075.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2901.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3404.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2243.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ABATACEPT 125 MG/ML SC SOSY|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00003218811_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.72, "maximum": 3636.54, "gross_charge": 3868.66, "discounted_cash": 2127.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2243.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3094.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3276.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1125.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1856.96, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2317.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2313.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3636.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3404.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1090.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3288.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2901.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1362.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2630.69, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3636.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3029.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3075.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2901.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3404.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2243.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ABATACEPT 250 MG IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00003218713", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.72, "maximum": 3735.29, "gross_charge": 3973.71, "discounted_cash": 2185.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2304.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3178.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3365.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1156.35, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1907.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2380.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2376.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3735.29, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3496.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1119.79, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3377.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2980.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1399.94, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2702.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3735.29, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3111.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3159.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2980.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3496.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2304.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Abd paracentesis", "code_information": [ { "code": "49082", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 691.08, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 67775.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 122978.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 122978.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Abd paracentesis w/imaging", "code_information": [ { "code": "49083", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 691.08, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2041.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3704.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3704.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ABIRATERONE ACETATE 250 MG PO TABS", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "60687079021", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.58, "maximum": 21.96, "gross_charge": 23.36, "discounted_cash": 12.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.55, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.69, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.21, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.58, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.55, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ablate bone tumor(s) perq", "code_information": [ { "code": "20982", "type": "HCPCS" }, { "code": "20983", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 33418.51, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 60638.42, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 60638.42, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ablate inf turbinate submuc", "code_information": [ { "code": "30802", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1091.85, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15415.22, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28328.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28328.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ablate inf turbinate superf", "code_information": [ { "code": "30801", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1091.85, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14226.88, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25814.89, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25814.89, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ablate pulm tumor perq crybl", "code_information": [ { "code": "32994", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13502.61, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24500.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24500.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ablate pulm tumor perq rf", "code_information": [ { "code": "32998", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14866.73, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26975.92, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26975.92, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Abltj mal prst8 tiss hifu", "code_information": [ { "code": "55880", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 6816.07, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5048.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14238.67, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25836.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6816.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25836.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Abltj perc plex/trncl nrv", "code_information": [ { "code": "0442T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4720.44, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3496.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10044.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18225.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4720.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18225.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ABOBOTULINUMTOXINA 300 UNITS IM SOLR", "drug_information": { "unit": "300.000000", "type": "UN" }, "code_information": [ { "code": "15054053006", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.71, "maximum": 1938.28, "gross_charge": 2062.0, "discounted_cash": 1134.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1195.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1649.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1746.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 600.04, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 989.76, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1235.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1233.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1938.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1814.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 581.07, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1752.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1546.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 726.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1402.16, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1938.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1614.55, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1639.29, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1546.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1814.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1195.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ABOBOTULINUMTOXINA 500 UNITS IM SOLR", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "15054050001", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.71, "maximum": 3229.84, "gross_charge": 3436.0, "discounted_cash": 1889.8, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1992.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2748.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2910.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 999.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1649.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2058.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2054.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3023.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 968.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2920.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2577.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1210.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2336.48, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2690.39, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2731.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2577.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3023.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1992.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Abortion", "code_information": [ { "code": "59841", "type": "HCPCS" }, { "code": "59840", "type": "HCPCS" }, { "code": "59850", "type": "HCPCS" }, { "code": "59851", "type": "HCPCS" }, { "code": "59855", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5932.49, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10764.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10764.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Abortion (mpr)", "code_information": [ { "code": "59866", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 224.22, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5523.46, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10022.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10022.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ABSORBABLE HEMOSTAT", "drug_information": { "unit": "5.000000", "type": "GR" }, "code_information": [ { "code": "82526100005", "type": "NDC" } ], "standard_charges": [ { "minimum": 156.92, "maximum": 1158.0, "gross_charge": 556.85, "discounted_cash": 306.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 322.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 483.35, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.04, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 267.29, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 523.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 490.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.92, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 473.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 417.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.18, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 378.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 523.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 436.01, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 442.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 417.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 490.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 322.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ABSORBASE EX OINT", "drug_information": { "unit": "454.000000", "type": "GR" }, "code_information": [ { "code": "46287050716", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.49, "maximum": 48.34, "gross_charge": 51.43, "discounted_cash": 28.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.97, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.69, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.49, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.97, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.27, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Access thoracic lymph duct", "code_information": [ { "code": "38794", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 40598.97, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 73667.49, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 73667.49, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACD FORMULA A 0.73-2.45-2.2 GM/100ML VI SOLN", "drug_information": { "unit": "750.000000", "type": "UN" }, "code_information": [ { "code": "14537081775", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", 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billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, 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}, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACD FORMULA A 0.73-2.45-2.2 GM/100ML VI SOLN (PEDS CRRT PRISMAFLEX)", "drug_information": { "unit": "750.000000", "type": "UN" }, "code_information": [ { "code": "14537081775_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, 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"additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN 10 MG/ML 0-50 ML SYRINGE", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00264410090_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN 10 MG/ML 0-50 ML SYRINGE (2 DAY MAX DURATION)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00264410090_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN 10 MG/ML 50-100 ML INTRAVIA", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00264410090_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN 10 MG/ML 50-100 ML INTRAVIA (2 DAY MAX DURATION)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00264410090_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN 10 MG/ML IV SOLN", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00264410090_6", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN 10 MG/ML IV SOLN (2 DAY MAX DURATION)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00264410090_7", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN 10 MG/ML SYRINGE (NICU)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00264410090", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN 120 MG RE SUPP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51672211502", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN 32 MG/ML PO LIQUID", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "68094013058", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN 325 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50580045811", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN 325 MG RE SUPP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51672211602", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904673061", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN 650 MG RE SUPP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "45802073032", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": 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88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN 80 MG PO CHEW", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904579146", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN-CODEINE 120-12 MG/5ML PO SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "1785607901", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.72, "maximum": 12.42, "gross_charge": 13.21, "discounted_cash": 7.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.34, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.98, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN-CODEINE 300-30 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00406048462", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN-CODEINE 300-60 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1310706001", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All 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charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAZOLAMIDE 100 MG/ML SYRINGE(PEDS)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "09992019007", "type": "NDC" } ], "standard_charges": [ { "minimum": 36.45, "maximum": 121.57, "gross_charge": 129.33, "discounted_cash": 71.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.08, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.56, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.27, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAZOLAMIDE 250 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268005415", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.2, "maximum": 4.0, "gross_charge": 4.26, "discounted_cash": 2.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.41, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.24, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.04, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.75, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.75, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAZOLAMIDE 25MG/ML ORAL SUSPENSION", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "P5167240231", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.14, "maximum": 3.82, "gross_charge": 4.06, "discounted_cash": 2.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.95, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.43, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.76, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.23, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAZOLAMIDE ER 500 MG PO CP12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687057821", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.14, "maximum": 7.15, "gross_charge": 7.61, "discounted_cash": 4.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.21, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.65, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.14, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.17, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAZOLAMIDE SODIUM 500 MG IJ SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "39822019001", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.67, "maximum": 62.28, "gross_charge": 66.25, "discounted_cash": 36.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.28, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.67, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.34, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.05, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETIC ACID 0.25 % IR SOLN", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338065604", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETIC ACID 2 % OT SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "52817081615", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.56, "maximum": 38.57, "gross_charge": 41.03, "discounted_cash": 22.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.94, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.69, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.56, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.45, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETIC ACID 3 % SOLN", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "P8252005130", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 1158.0, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETIC ACID 5% SOLN", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "P4444075330", "type": "NDC" }, { "code": "P4444075360", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 1158.0, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETYLCHOLINE CHLORIDE 20 MG IO SOLR", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "24208053920", "type": "NDC" } ], "standard_charges": [ { "minimum": 20.52, "maximum": 1158.0, "gross_charge": 72.82, "discounted_cash": 40.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.21, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.19, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.95, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.52, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.52, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.02, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETYLCHOLINE INTRACORONARY SYRINGE", "drug_information": { "unit": "12.000000", "type": "UN" }, "code_information": [ { "code": "09991000125", "type": "NDC" } ], "standard_charges": [ { "minimum": 73.79, "maximum": 1158.0, "gross_charge": 261.85, "discounted_cash": 144.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 227.29, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.2, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.69, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.79, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.25, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.06, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.03, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 208.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETYLCYSTEINE 20 % IN SOLN", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00517760425_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.63, "maximum": 8.78, "gross_charge": 9.34, "discounted_cash": 5.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.29, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.35, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.31, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETYLCYSTEINE 20 % IN SOLN (INHALATION)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00517760425", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETYLCYSTEINE 200 MG/ML IV SOLN", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "72611086004", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.61, "maximum": 78.75, "gross_charge": 83.78, "discounted_cash": 46.08, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.21, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.61, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.52, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.97, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.6, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETYLCYSTEINE OPHTHALMIC SOLN 20%", "drug_information": { "unit": "12.000000", "type": "UN" }, "code_information": [ { "code": "08252000247", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 1158.0, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.48, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACITRETIN 10 MG PO CAPS", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "42794008008", "type": "NDC" } ], "standard_charges": [ { "minimum": 47.78, "maximum": 159.39, "gross_charge": 169.56, "discounted_cash": 93.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.34, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.39, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.78, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.74, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACITRETIN 25 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "42794008308", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.63, "maximum": 65.49, "gross_charge": 69.67, "discounted_cash": 38.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.44, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.54, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.38, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.55, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACTIDOSE WITH SORBITOL 25 GM/120ML PO SUSP", "drug_information": { "unit": "120.000000", "type": "UN" }, "code_information": [ { "code": "66689020304", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.32, "maximum": 37.77, "gross_charge": 40.18, "discounted_cash": 22.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.69, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.29, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.32, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.16, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACYCLOVIR 200 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904578961", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACYCLOVIR 200 MG/5ML PO SUSP", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "2315548551", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACYCLOVIR 400 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268006115", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACYCLOVIR 5 % EX OINT", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "72578008201", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.13, "maximum": 33.79, "gross_charge": 35.95, "discounted_cash": 19.77, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.26, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.67, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.45, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.15, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACYCLOVIR 800 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084010901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACYCLOVIR SODIUM 50 MG/ML IV SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "55150015520", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.4, "maximum": 44.7, "gross_charge": 47.55, "discounted_cash": 26.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.84, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.4, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.33, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ADALIMUMAB 20 MG/0.2ML SC PSKT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00074061602", "type": "NDC" } ], "standard_charges": [ { 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{ "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2736.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4514.27, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5633.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5624.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8840.45, "standard_charge_percentage": 94.0, "methodology": 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"standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6626.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12790.47, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17680.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14727.85, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": 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billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10269.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ADALIMUMAB-ATTO 40 MG/0.8ML SC SOAJ", "drug_information": { "unit": "0.800000", "type": "UN" }, "code_information": [ { "code": "72511040001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1277.29, "maximum": 4260.65, "gross_charge": 4532.61, "discounted_cash": 2492.94, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2628.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2474.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3626.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3839.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1318.99, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2175.65, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", 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charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3852.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3399.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1596.84, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3082.17, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4260.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3549.03, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2474.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3603.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3399.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3988.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2628.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2474.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ADEFOVIR DIPIVOXIL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "42794000308", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.97, "maximum": 46.6, "gross_charge": 49.57, "discounted_cash": 27.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.42, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.79, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.97, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.46, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.71, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.41, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "55150019301", "type": "NDC" } ], "standard_charges": [ { "minimum": 127.75, "maximum": 426.12, "gross_charge": 453.32, "discounted_cash": 249.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 262.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 362.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 383.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.59, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 271.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 271.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 426.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 398.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.75, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 385.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 339.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.7, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.26, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 426.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 354.95, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 360.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 339.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 398.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 262.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ADENOSINE 6 MG/2ML IV SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "67457085502", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 807.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 712.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 334.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 893.0, "standard_charge_percentage": 94.0, 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"standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 551.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AFLIBERCEPT 2 MG/0.05ML IZ SOLN", "drug_information": { "unit": "0.050000", "type": "UN" }, "code_information": [ { "code": "61755000502", "type": "NDC" } ], "standard_charges": [ { "minimum": 448.8, "maximum": 3476.67, "gross_charge": 3698.58, "discounted_cash": 2034.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2145.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 448.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2958.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3132.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1076.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1775.32, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2215.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2211.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3476.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3254.75, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1042.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3143.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2773.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1303.01, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 2773.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3254.75, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2145.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 448.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "AFLIBERCEPT 2 MG/0.05ML IZ SOSY", "drug_information": { "unit": "0.050000", "type": "UN" }, "code_information": [ { "code": "61755000501", "type": "NDC" } ], "standard_charges": [ { "minimum": 448.8, "maximum": 5217.0, "gross_charge": 5550.0, "discounted_cash": 3052.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3219.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 448.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4440.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4700.85, "standard_charge_percentage": 85.0, "methodology": "percent of total 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"methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4884.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1563.99, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4717.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4162.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1955.27, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3774.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5217.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4345.65, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 605.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue 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schedule" } ], "additional_generic_notes": "" } ] }, { "description": "AFLIBERCEPT 8 MG/0.07ML IZ SOLN", "drug_information": { "unit": "0.070000", "type": "UN" }, "code_information": [ { "code": "61755005001", "type": "NDC" } ], "standard_charges": [ { "minimum": 182.2, "maximum": 5602.83, "gross_charge": 5960.46, "discounted_cash": 3278.25, "setting": "outpatient", "payers_information": [ { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4768.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1679.66, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4738.57, 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Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5245.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2861.02, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2099.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3457.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3457.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5602.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4667.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3564.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5602.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "After cataract laser surgery", "code_information": [ { "code": "66821", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 404.37, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1049.36, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1904.09, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1904.09, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 404.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "AGALSIDASE BETA 35 MG IV SOLR", "drug_information": { "unit": "7.000000", "type": "UN" }, "code_information": [ { "code": "58468004001", "type": "NDC" } ], "standard_charges": [ { "minimum": 6302.23, "maximum": 21022.34, "gross_charge": 22364.19, "discounted_cash": 12300.3, "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18942.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19009.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16773.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10734.81, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7878.9, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12971.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6507.98, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16773.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19680.49, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12971.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21022.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17511.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12210.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", 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"plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15207.65, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12210.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17891.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6302.23, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AGALSIDASE BETA 5 MG IV SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "58468004101", "type": "NDC" } ], "standard_charges": [ { "minimum": 900.17, "maximum": 3002.68, "gross_charge": 3194.34, "discounted_cash": 1756.89, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1910.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3002.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1533.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1125.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1852.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2705.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2715.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2395.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1744.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2811.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1744.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1913.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2172.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1744.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 929.55, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2395.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2811.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2555.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 900.17, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2539.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1852.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3002.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2501.17, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Air injection into abdomen", "code_information": [ { "code": "49400", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13993.79, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25391.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25391.96, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBENDAZOLE 200 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "43598045202", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.62, "maximum": 12.07, "gross_charge": 12.84, "discounted_cash": 7.06, "setting": "outpatient", "payers_information": [ { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.62, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.05, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.74, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.73, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.52, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUMIN HUMAN 25 % IV SOLN (MULTI-GPI)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "68516521609", "type": "NDC" } ], "standard_charges": [ { "minimum": 60.31, "maximum": 201.16, "gross_charge": 214.0, "discounted_cash": 117.7, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.39, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.52, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUMIN HUMAN 25 % IV SOLN (MULTI-GPI) HRS", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "68516521609_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 60.31, "maximum": 201.16, "gross_charge": 214.0, "discounted_cash": 117.7, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.52, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.39, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUMIN HUMAN 25 % IV SOLN 50ML VIAL (BULK CHARGE)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "68516521609_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 60.31, "maximum": 201.16, "gross_charge": 214.0, "discounted_cash": 117.7, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.39, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.52, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUMIN HUMAN 25 % IV SOLN FOR REPLACEMENT FLUIDS", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "68516521609_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 60.31, "maximum": 201.16, "gross_charge": 214.0, "discounted_cash": 117.7, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.39, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.52, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUMIN HUMAN 5 % IV SOLN", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "68516521804", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.98, "maximum": 201.16, "gross_charge": 214.0, "discounted_cash": 117.7, "setting": "outpatient", "payers_information": [ { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.52, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.98, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.39, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.98, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUMIN HUMAN 5 % IV SOLN 250 ML BOTTLE (BULK CHARGE)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "68516521401", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.98, "maximum": 201.16, "gross_charge": 214.0, "discounted_cash": 117.7, "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.39, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.98, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.52, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.98, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUMIN HUMAN 5 % IV SOLN FOR REPLACEMENT FLUIDS", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "68516521401_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.98, "maximum": 201.16, "gross_charge": 214.0, "discounted_cash": 117.7, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.39, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.52, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.98, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.98, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUMIN HUMAN 5 % SOLN (APHERESIS DOSE)", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "68516521402", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.98, "maximum": 235.0, "gross_charge": 250.0, "discounted_cash": 137.5, "setting": "outpatient", "payers_information": [ { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.98, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.75, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.98, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 211.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUMIN HUMAN 5 % SOLN (APHERESIS)", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "68516521402_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.98, "maximum": 235.0, "gross_charge": 250.0, "discounted_cash": 137.5, "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 211.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.75, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.98, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.98, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "60687039583", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUTEROL SULFATE (5 MG/ML) 0.5% IN NEBU", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "69374033005", "type": "NDC" }, { "code": "00487990130", "type": "NDC" }, { "code": "73177014632", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.05, "maximum": 23.5, "gross_charge": 25.0, "discounted_cash": 13.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.58, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.28, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.05, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" }, { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" }, { "minimum": 10.57, "maximum": 35.25, "gross_charge": 37.5, "discounted_cash": 20.63, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.21, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.36, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.57, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.91, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUTEROL SULFATE (5MG/ML) IN NEBU 0.5 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "69374033005_2", "type": "NDC" }, { "code": "00487990130_2", "type": "NDC" }, { "code": "73177014632_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.05, "maximum": 23.5, "gross_charge": 25.0, "discounted_cash": 13.75, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.05, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.58, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.28, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" }, { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "outpatient", "payers_information": [ { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" }, { "minimum": 10.57, "maximum": 35.25, "gross_charge": 37.5, "discounted_cash": 20.63, "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.91, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.36, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.21, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.57, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUTEROL SULFATE 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084094925", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.79, "maximum": 9.32, "gross_charge": 9.91, "discounted_cash": 5.45, "setting": "outpatient", "payers_information": [ { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.74, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.79, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.76, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.76, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUTEROL SULFATE 2.5 MG/0.5ML IN NEBU", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "00487990130_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUTEROL SULFATE 5 MG/ML CONTINUOUS NEBULIZATION (503B)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "69374033005_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.05, "maximum": 23.5, "gross_charge": 25.0, "discounted_cash": 13.75, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.05, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.58, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.28, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUTEROL SULFATE 5 MG/ML CONTINUOUS NEBULIZATION MAINTENANCE", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "69374033005_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.05, "maximum": 23.5, "gross_charge": 25.0, "discounted_cash": 13.75, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.05, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.58, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.28, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUTEROL SULFATE HFA 108 (90 BASE) 8 GM INHALER (OR BULK CHARGE)", "drug_information": { "unit": "8.000000", "type": "GR" }, "code_information": [ { "code": "00173068224", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.35, "maximum": 47.87, "gross_charge": 50.93, "discounted_cash": 28.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.35, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.63, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.88, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.45, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.94, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.82, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS", "drug_information": { "unit": "8.000000", "type": "GR" }, "code_information": [ { "code": "00173068224_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.35, "maximum": 47.87, "gross_charge": 50.93, "discounted_cash": 28.01, "setting": "inpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.82, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.63, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.45, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.94, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.35, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.88, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALDESLEUKIN 22000000 UNITS IV SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "73776002201", "type": "NDC" } ], "standard_charges": [ { "minimum": 2894.49, "maximum": 15655.15, "gross_charge": 16654.41, "discounted_cash": 9159.93, "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14106.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14156.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12490.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13323.53, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4693.21, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13240.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2894.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14655.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3907.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9975.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11325.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2894.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9959.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15655.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4846.43, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12490.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14655.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9659.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15655.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13040.4, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7994.12, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5867.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9659.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALENDRONATE SODIUM 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1671463101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALENDRONATE SODIUM 35 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "69097022316", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALENDRONATE SODIUM 70 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64980034214", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALFUZOSIN HCL ER 10 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "57237011490", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "outpatient", "payers_information": [ { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALGLUCOSIDASE ALFA 50 MG IV SOLR (LUMIZYME)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "58468016001", "type": "NDC" } ], "standard_charges": [ { "minimum": 110.28, "maximum": 3626.26, "gross_charge": 3857.72, "discounted_cash": 2121.75, "setting": "outpatient", "payers_information": [ { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3086.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1087.11, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3066.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1851.71, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1359.07, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2237.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2306.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3626.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1122.6, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2893.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3394.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3394.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3267.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3279.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2893.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2237.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3626.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3020.59, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2310.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2623.25, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ALIROCUMAB 75 MG/ML SC SOAJ", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "61755002002", "type": "NDC" } ], "standard_charges": [ { "minimum": 226.22, "maximum": 754.59, "gross_charge": 802.76, "discounted_cash": 441.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 465.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 754.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 628.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 679.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 682.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 602.07, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 642.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.22, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 638.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 233.6, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 602.07, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 706.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 385.32, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 465.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 480.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 545.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 438.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 438.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 706.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 438.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 480.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 754.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALISKIREN FUMARATE 150 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "66993014130", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.83, "maximum": 9.43, "gross_charge": 10.03, "discounted_cash": 5.52, "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.82, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.81, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.53, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.83, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.85, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALISKIREN FUMARATE 300 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "49884042511", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.46, "maximum": 14.88, "gross_charge": 15.83, "discounted_cash": 8.71, "setting": "outpatient", "payers_information": [ { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.76, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.61, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.39, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Allgrft implnt knee w/scope", "code_information": [ { "code": "29867", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 26376.2, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47870.82, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47870.82, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ALLOPURINOL 0.2 MG/ML SUSPENSION", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "P0378013710", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALLOPURINOL 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687067701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALLOPURINOL 20 MG/ML ORAL SUSPENSION", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "P0378013701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALLOPURINOL 300 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687068801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALLOPURINOL 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "0378013701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "outpatient", "payers_information": [ { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALLOPURINOL SODIUM 500 MG IV SOLR", "drug_information": { "unit": "500.000000", "type": "ME" }, "code_information": [ { "code": "67457018750", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.73, "maximum": 3167.06, "gross_charge": 3369.21, "discounted_cash": 1853.07, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1954.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3167.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2638.09, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2014.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3167.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 949.44, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2678.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 980.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2526.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2964.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2853.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2863.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2526.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2964.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.69, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2018.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2291.06, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1617.22, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1186.97, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1954.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALPHA-LIPOIC ACID 600 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "47469004472", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "ME" }, "code_information": [ { "code": "13533070501_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.7, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "ME" }, "code_information": [ { "code": "13533070501", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.35, "maximum": 3.64, "gross_charge": 1.25, "discounted_cash": 0.69, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.35, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.98, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALPHA1-PROTEINASE INHIBITOR 1000 MG/50ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "ME" }, "code_information": [ { "code": "00944288401_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALPHA1-PROTEINASE INHIBITOR 1000 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "ME" }, "code_information": [ { "code": "00944288401", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.45, "maximum": 1.5, "gross_charge": 1.6, "discounted_cash": 0.88, "setting": "outpatient", "payers_information": [ { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.47, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.77, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.56, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.25, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALPRAZOLAM 0.25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687037701", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALPRAZOLAM 0.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687038801", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALPRAZOLAM 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R5976237211", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALPRAZOLAM 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00781108901", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALPRAZOLAM ER 0.5 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00228308306", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALPROSTADIL (VASODILATOR) 20 MCG IC SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00009370105", "type": "NDC" } ], "standard_charges": [ { "minimum": 80.41, "maximum": 1158.0, "gross_charge": 285.34, "discounted_cash": 156.94, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.68, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.03, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.96, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 251.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 214.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.53, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.42, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 214.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 251.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALPROSTADIL 500 MCG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00009316906", "type": "NDC" } ], "standard_charges": [ { "minimum": 115.76, "maximum": 1158.0, "gross_charge": 410.8, "discounted_cash": 225.94, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 356.57, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.54, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.18, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 386.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 361.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.72, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 279.34, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 386.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 321.66, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 326.59, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 361.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALTEPLASE 100 MG IV SOLR", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "50242008527", "type": "NDC" } ], "standard_charges": [ { "minimum": 7216.63, "maximum": 24072.51, "gross_charge": 25609.05, "discounted_cash": 14084.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14853.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13982.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20487.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21690.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7452.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12292.34, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15339.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24072.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22535.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7216.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21767.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19206.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9022.07, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17414.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24072.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20051.89, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13982.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19206.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22535.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14853.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13982.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALTEPLASE 100 MG IV SOLR (PE)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "50242008527_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 7236.36, "maximum": 24138.31, "gross_charge": 25679.05, "discounted_cash": 14123.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14893.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14020.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20543.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21750.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7472.6, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12325.94, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15381.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24138.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22597.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7236.36, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21827.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19259.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9046.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17461.75, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24138.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20106.7, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14020.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19259.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22597.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14893.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14020.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALTEPLASE 100 MG IV SOLR (PE)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "50242008527_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 7216.63, "maximum": 24072.51, "gross_charge": 25609.05, "discounted_cash": 14084.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14853.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13982.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20487.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21690.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7452.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12292.34, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15339.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24072.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22535.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7216.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21767.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19206.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9022.07, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17414.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24072.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20051.89, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13982.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19206.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22535.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14853.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13982.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALTEPLASE 2 MG IJ SOLR", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "50242004164", "type": "NDC" } ], "standard_charges": [ { "minimum": 49.94, "maximum": 562.79, "gross_charge": 598.71, "discounted_cash": 329.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 478.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 507.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 287.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 562.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 526.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 508.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 449.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 407.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 562.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 449.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 526.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ALTEPLASE 2 MG IJ SOLR (APHERESIS)", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "50242004164_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 49.94, "maximum": 562.79, "gross_charge": 598.71, "discounted_cash": 329.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 478.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 507.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 287.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 562.79, "standard_charge_percentage": 94.0, 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"additional_payer_notes": "N/A", "standard_charge_dollar": 210.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 407.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 562.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue 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schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ALTEPLASE 2 MG IJ SOLR FOR 0.5 MG DOSE FOR IV LINE DECLOTTING", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "50242004164_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 49.94, "maximum": 562.79, "gross_charge": 598.71, "discounted_cash": 329.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 478.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 507.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 287.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", 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"standard_charge_dollar": 347.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ALTEPLASE 2 MG IJ SOLR FOR 1 MG DOSE FOR IV LINE DECLOTTING", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50242004164_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 49.94, "maximum": 562.79, "gross_charge": 598.71, "discounted_cash": 329.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 478.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 507.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 287.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 562.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 526.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 508.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 449.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 407.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 562.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 449.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 526.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ALTEPLASE 2 MG IJ SOLR FOR 2 MG DOSE FOR IV LINE DECLOTTING", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "50242004164_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 49.94, "maximum": 562.79, "gross_charge": 598.71, "discounted_cash": 329.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 478.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 507.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 287.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 562.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 526.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 508.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 449.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 407.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 562.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 449.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 526.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ALTEPLASE 50 MG IV SOLR", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "50242004413", "type": "NDC" } ], "standard_charges": [ { "minimum": 3608.32, "maximum": 12036.27, "gross_charge": 12804.54, "discounted_cash": 7042.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7426.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6991.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10243.63, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10845.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3726.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6146.18, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7669.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7657.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12036.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11268.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3608.32, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10883.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9603.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4511.04, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8707.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12036.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10025.95, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6991.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10179.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9603.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11268.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7426.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6991.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALUM & MAG HYDROXIDE-SIMETH 400-400-40 MG/5ML PO SUSP", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "00121176230", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.08, "maximum": 6.93, "gross_charge": 7.37, "discounted_cash": 4.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.14, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.54, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.49, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.01, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.49, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALUM HYDROXIDE-MAG CARBONATE 95-358 MG/15ML PO SUSP", "drug_information": { "unit": "355.000000", "type": "UN" }, "code_information": [ { "code": "00904772714", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.12, "maximum": 7.08, "gross_charge": 7.53, "discounted_cash": 4.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.19, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.61, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.12, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.9, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALUM POTASSIUM SULFATE 10% IRRIGATION SOLN", "drug_information": { "unit": "300.000000", "type": "UN" }, "code_information": [ { "code": "05446063730", "type": "NDC" } ], "standard_charges": [ { "minimum": 70.45, "maximum": 1158.0, "gross_charge": 250.0, "discounted_cash": 137.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.0, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.75, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALUMINUM CHLORIDE 20 % EX SOLN", "drug_information": { "unit": "35.000000", "type": "UN" }, "code_information": [ { "code": "00096070735", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.42, "maximum": 18.1, "gross_charge": 19.25, "discounted_cash": 10.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.6, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.24, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.42, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.07, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALUMINUM HYDROXIDE GEL 320 MG/5ML PO SUSP", "drug_information": { "unit": "473.000000", "type": "UN" }, "code_information": [ { "code": "00536009185", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.84, "maximum": 9.48, "gross_charge": 10.08, "discounted_cash": 5.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.84, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.55, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.85, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.89, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMANTADINE HCL 100 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687042201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMANTADINE HCL 50 MG/5ML PO SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00121064610", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.97, "maximum": 6.58, "gross_charge": 7.0, "discounted_cash": 3.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.04, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.36, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.97, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.76, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMBRISENTAN 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00591240630", "type": "NDC" } ], "standard_charges": [ { "minimum": 70.62, "maximum": 235.55, "gross_charge": 250.59, "discounted_cash": 137.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.62, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.28, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.21, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 199.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMBRISENTAN 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378427093", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.82, "maximum": 36.09, "gross_charge": 38.39, "discounted_cash": 21.11, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.71, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.43, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.82, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.52, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.11, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.06, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIKACIN INTRAVITREAL INJ (0.2MG/0.1ML)", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "08252003300", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIKACIN INTRAVITREAL INJ (0.4MG/0.1ML)", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "08252003400", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIKACIN INTRAVITREAL INJ (0.6MG/0.1ML)", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "08252000300", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIKACIN OPHTHALMIC SOLN 25 MG/ML", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "08252001900", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIKACIN SULFATE 1 G/4 ML IJ SOLN FOR INHALATION", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "23155029042_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIKACIN SULFATE 1 GM/4ML IJ SOLN", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "23155029042", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIKACIN SULFATE 500 MG/2ML IJ SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00641616710", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMILORIDE HCL 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0574029201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMINO ACID 5 % IV SOLN", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "71266802001", "type": "NDC" } ], "standard_charges": [ { "minimum": 227.55, "maximum": 759.05, "gross_charge": 807.5, "discounted_cash": 444.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 440.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 683.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 234.98, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 387.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 483.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 482.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 759.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 710.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 227.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 686.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 605.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 549.1, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 759.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 632.27, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 440.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 641.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 605.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 710.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 440.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMINO ACID INFUSION IN D10W 3 % IV SOLN (503B)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "72196040401", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.55, "maximum": 1158.0, "gross_charge": 44.55, "discounted_cash": 24.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.67, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.96, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.29, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.88, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMINO ACID INFUSION IN D10W 3 % W/ CALCIUM GLUC 2.33 MEQ HEPARIN 125 UNITS IV SOLN (503B)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "72196042801", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.01, "maximum": 1158.0, "gross_charge": 49.7, "discounted_cash": 27.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.14, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.86, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.01, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.51, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMINO ACID INFUSION IN D10W 4.25 % IV SOLN", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338113403", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.65, "maximum": 1158.0, "gross_charge": 30.69, "discounted_cash": 16.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.64, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.01, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.65, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.87, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.03, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.01, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { 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"methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1514.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1417.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 453.99, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1369.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": 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{ "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 879.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1280.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1208.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1417.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 934.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 879.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMINOCAPROIC ACID 250 MG/ML IV SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00517912025", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMINOCAPROIC ACID 500 MG PO TABS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "60687073925", "type": "NDC" } ], "standard_charges": [ { "minimum": 20.18, "maximum": 67.32, "gross_charge": 71.62, "discounted_cash": 39.39, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.84, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.7, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMINOLEVULINIC ACID HCL 1.5 G PO SOLR", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "59137023101", "type": "NDC" } ], "standard_charges": [ { "minimum": 3602.53, "maximum": 12016.96, "gross_charge": 12784.0, "discounted_cash": 7031.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7414.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6980.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10227.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10828.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3720.14, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6136.32, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7657.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7644.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12016.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11249.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3602.53, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10866.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9588.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4503.8, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8693.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12016.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10009.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6980.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10163.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9588.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11249.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7414.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6980.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMINOLEVULINIC ACID HCL 20 % EX SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "67308010106", "type": "NDC" } ], "standard_charges": [ { "minimum": 216.75, "maximum": 1317.73, "gross_charge": 1401.84, "discounted_cash": 771.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 813.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.75, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1121.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1187.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 407.94, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.88, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 839.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 838.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1317.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1233.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 395.04, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1191.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1051.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 493.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 953.25, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1317.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1097.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 292.61, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1114.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1051.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1233.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 813.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.75, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "AMINOPHYLLINE 2 MG/ML SOLUTION", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "P0409592101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMINOPHYLLINE 25 MG/ML IV SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00409592201", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIODARONE 10MG/ML SUSPENSION", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "08252000155", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIODARONE HCL 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00245014401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIODARONE HCL 150 MG/100 ML DRIP RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "43066015010", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIODARONE HCL 150 MG/3 ML IV SOLN 3 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00143987525", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIODARONE HCL 150 MG/3ML IV SOLN", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00143987525_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIODARONE HCL 150 MG/3ML IV SOLN -CODE USE PEDS", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00143987525_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIODARONE HCL 200 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687043701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIODARONE HCL 360 MG/200 ML DRIP RTU", "drug_information": { "unit": "200.000000", "type": "UN" }, "code_information": [ { "code": "43066036020", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIODARONE HCL 450 MG/9ML IV SOLN", "drug_information": { "unit": "9.000000", "type": "UN" }, "code_information": [ { "code": "63323061609", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIODARONE HCL 900 MG/18ML IV SOLN", "drug_information": { "unit": "18.000000", "type": "UN" }, "code_information": [ { "code": "67457015318", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMITRIPTYLINE HCL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268003715", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMITRIPTYLINE HCL 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R1672917501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMITRIPTYLINE HCL 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687043301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMITRIPTYLINE HCL 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687044401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMITRIPTYLINE HCL 75 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1657110801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIVANTAMAB-VMJW 350 MG/7ML IV SOLN", "drug_information": { "unit": "7.000000", "type": "UN" }, "code_information": [ { "code": "57894050101", "type": "NDC" } ], "standard_charges": [ { "minimum": 3082.62, "maximum": 10282.71, "gross_charge": 10939.05, "discounted_cash": 6016.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6344.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5972.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8751.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9265.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3183.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5250.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6552.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6541.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10282.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9626.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3082.62, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9298.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8204.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3853.83, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7438.55, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10282.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8565.28, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5972.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8696.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8204.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9626.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6344.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5972.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMLODIPINE BENZOATE 1 MG/ML PO SUSP", "drug_information": { "unit": "150.000000", "type": "UN" }, "code_information": [ { "code": "52652500101", "type": "NDC" } ], "standard_charges": [ { "minimum": 374.48, "maximum": 1249.17, "gross_charge": 1328.9, "discounted_cash": 730.9, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 770.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 725.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1063.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1125.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 386.71, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 637.87, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 796.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 794.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1249.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1169.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 374.48, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1129.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 996.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.17, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 903.65, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1249.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1040.53, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 725.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1056.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 996.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1169.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 770.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 725.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMLODIPINE BESY-BENAZEPRIL HCL 10-40 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078037905", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.38, "maximum": 34.64, "gross_charge": 36.85, "discounted_cash": 20.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.72, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.69, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.38, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.06, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.85, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMLODIPINE BESY-BENAZEPRIL HCL 5-10 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078040505", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.68, "maximum": 25.62, "gross_charge": 27.26, "discounted_cash": 14.99, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.08, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.54, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMLODIPINE BESYLATE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687049601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMLODIPINE BESYLATE 2.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904636961", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMLODIPINE BESYLATE 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687048801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMMONIA AROMATIC IN INHA", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252062022", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMMONIUM LACTATE 12 % EX LOTN", "drug_information": { "unit": "226.000000", "type": "GR" }, "code_information": [ { "code": "00904598426", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.47, "maximum": 8.25, "gross_charge": 8.78, "discounted_cash": 4.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.09, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.55, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.21, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.97, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.09, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMOXICILLIN 125 MG/5ML PO SUSR", "drug_information": { "unit": "80.000000", "type": "UN" }, "code_information": [ { "code": "00781603958", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.54, "maximum": 5.15, "gross_charge": 5.48, "discounted_cash": 3.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.59, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.63, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.54, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.73, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMOXICILLIN 250 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0781202001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMOXICILLIN 250 MG PO CHEW", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00093226801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMOXICILLIN 250 MG/5ML PO SUSR", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00143988901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.49, "maximum": 4.98, "gross_charge": 5.3, "discounted_cash": 2.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.54, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.54, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.49, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.15, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMOXICILLIN 400 MG/5ML PO SUSR", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "65862007150", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.76, "maximum": 5.86, "gross_charge": 6.23, "discounted_cash": 3.43, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.81, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.99, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.19, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.24, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.88, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMOXICILLIN 500 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0781261305", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMOXICILLIN 875 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00093226401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMOXICILLIN-POT CLAVULANATE 250-125 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687078194", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.12, "maximum": 7.07, "gross_charge": 7.52, "discounted_cash": 4.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.19, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.61, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.12, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.11, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.89, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMOXICILLIN-POT CLAVULANATE 250-62.5 MG/5ML PO SUSR", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "60432006500", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.68, "maximum": 18.94, "gross_charge": 20.15, "discounted_cash": 11.08, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.86, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.67, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.1, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.7, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMOXICILLIN-POT CLAVULANATE 400-57 MG/5ML PO SUSR", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "65862053450", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.36, "maximum": 7.88, "gross_charge": 8.38, "discounted_cash": 4.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.02, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.36, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.95, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.7, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMOXICILLIN-POT CLAVULANATE 500-125 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687079201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.39, "maximum": 4.64, "gross_charge": 4.94, "discounted_cash": 2.72, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.37, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.39, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.74, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.36, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5ML PO SUSR", "drug_information": { "unit": "75.000000", "type": "UN" }, "code_information": [ { "code": "00781613957", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.24, "maximum": 14.13, "gross_charge": 15.03, "discounted_cash": 8.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.21, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.24, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.3, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.22, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687080301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.43, "maximum": 4.78, "gross_charge": 5.09, "discounted_cash": 2.8, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.48, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.44, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.43, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.46, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.99, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMOXICILLIN-POT CLAVULANATE ER 1000-62.5 MG PO TB12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00781194382", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.04, "maximum": 10.14, "gross_charge": 10.79, "discounted_cash": 5.93, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.63, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.14, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.18, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.04, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.8, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.34, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHETAMINE-DEXTROAMPHET ER 10 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "3172218601", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", 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"payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, 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"standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHETAMINE-DEXTROAMPHET ER 15 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "3172218701", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", 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"percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHETAMINE-DEXTROAMPHET ER 20 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "54092038701", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.55, "maximum": 15.16, "gross_charge": 16.13, "discounted_cash": 8.87, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.69, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.97, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.63, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHETAMINE-DEXTROAMPHET ER 25 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "54092038901", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.55, "maximum": 15.16, "gross_charge": 16.13, "discounted_cash": 8.87, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.69, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.97, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.63, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHETAMINE-DEXTROAMPHET ER 5 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "3172218501", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHETAMINE-DEXTROAMPHETAMINE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1153419201", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { 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"methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": 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total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHETAMINE-DEXTROAMPHETAMINE 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00527150537", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, 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6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHETAMINE-DEXTROAMPHETAMINE 30 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00555097402", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHETAMINE-DEXTROAMPHETAMINE 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0555097102", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN B 0.167 MG/ML SUSPENSION", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "P3982210555", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN B 5 MG/ML SUSPENSION", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "P3982210557", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.68, "maximum": 8.93, "gross_charge": 9.5, "discounted_cash": 5.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.76, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.46, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.44, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN B 50 MG IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "39822105505", "type": "NDC" } ], "standard_charges": [ { "minimum": 24.22, "maximum": 80.79, "gross_charge": 85.95, "discounted_cash": 47.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.26, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.22, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.28, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.45, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.33, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN B 50 MG IV SOLR (INTRA-ARTICULAR ONLY)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "39822105505_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 24.22, "maximum": 80.79, "gross_charge": 85.95, "discounted_cash": 47.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.26, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.22, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.28, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.45, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.33, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN B LIPID 5 MG/ML IV SUSP", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "57665010141", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.08, "maximum": 268.18, "gross_charge": 285.3, "discounted_cash": 156.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 228.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 241.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.02, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.94, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 251.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.4, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.39, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 251.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN B LIPID CPLX (ABELCET) INH SYR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "57665010141_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.08, "maximum": 268.18, "gross_charge": 285.3, "discounted_cash": 156.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 228.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 241.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.02, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.94, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 251.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.4, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.39, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 251.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN B LIPOSOME (AMBISOME) INH SYR", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00469305130", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.74, "maximum": 263.95, "gross_charge": 280.8, "discounted_cash": 154.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.74, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 237.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.71, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.78, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 263.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 263.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 219.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.74, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN B LIPOSOME (AMBISOME) INH SYR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00469305130_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.74, "maximum": 263.95, "gross_charge": 280.8, "discounted_cash": 154.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.74, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 237.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.71, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.78, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 263.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 263.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 219.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.74, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN B LIPOSOME 2 MG/ML LOCK SYRINGE", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00469305130_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.74, "maximum": 329.75, "gross_charge": 350.8, "discounted_cash": 192.94, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.74, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 280.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 297.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.08, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 329.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.86, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 298.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 263.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.54, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 329.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 274.68, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 278.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 263.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.74, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN B LIPOSOME 50 MG IV SUSR", "drug_information": { "unit": "13.000000", "type": "UN" }, "code_information": [ { "code": "00469305130_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.74, "maximum": 615.89, "gross_charge": 655.2, "discounted_cash": 360.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 380.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.74, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 524.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 554.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.66, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 314.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 392.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 391.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 615.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 576.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.64, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 556.92, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 491.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.83, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 445.54, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 615.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 513.02, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 520.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 491.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 576.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 380.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.74, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN B LIPOSOME 50 MG IV SUSR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "13.000000", "type": "UN" }, "code_information": [ { "code": "00469305130_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.74, "maximum": 263.95, "gross_charge": 280.8, "discounted_cash": 154.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.74, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 237.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.71, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.78, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 263.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 263.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 219.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.74, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN B OPHTHALMIC SOLN 1.5 MG/ML", "drug_information": { "unit": "0.050000", "type": "UN" }, "code_information": [ { "code": "9993000510_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN B OPHTHALMIC SOLN 5 MG/ML", "drug_information": { "unit": "0.050000", "type": "UN" }, "code_information": [ { "code": "9993000510", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN INTRAVITREAL INJ (10MCG/0.1ML)", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "08252000158", "type": "NDC" } ], "standard_charges": [ { "minimum": 56.06, "maximum": 186.98, "gross_charge": 198.92, "discounted_cash": 109.41, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.89, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.06, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 169.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.27, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN INTRAVITREAL INJ (5MCG/0.05ML)", "drug_information": { "unit": "0.050000", "type": "UN" }, "code_information": [ { "code": "9986000501", "type": "NDC" } ], "standard_charges": [ { "minimum": 55.99, "maximum": 186.76, "gross_charge": 198.68, "discounted_cash": 109.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.82, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.37, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.99, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.99, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.1, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.57, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN INTRAVITREAL INJ (5MCG/0.1ML)", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "9986000501_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 55.99, "maximum": 186.76, "gross_charge": 198.68, "discounted_cash": 109.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.82, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.37, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.99, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.99, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.1, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.57, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPICILLIN 500 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00781214501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", 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Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": 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"standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPICILLIN SODIUM 1 G IJ SOLR", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "00781340495", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": 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"standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPICILLIN SODIUM 100 MG/ML IJ 500 MG VIAL (RECON)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00781340795", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", 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"Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPICILLIN SODIUM 2 G IJ SOLR", "drug_information": { "unit": "8.000000", "type": "UN" }, "code_information": [ { "code": "72485042210", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPICILLIN SODIUM 250 MG IJ SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00781340295", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPICILLIN SODIUM 500 MG IJ SOLR", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00781340795_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPICILLIN SUBCONJUNCTIVAL INJ (125 MG/0.5 ML)", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "08252001500", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "25021014220", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPICILLIN-SULBACTAM SODIUM 15 (10-5) G IV SOLR", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "55150011899", "type": "NDC" } ], "standard_charges": [ { "minimum": 50.39, "maximum": 168.07, "gross_charge": 178.8, "discounted_cash": 98.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.03, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.39, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.99, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.58, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR", "drug_information": { "unit": "8.000000", "type": "UN" }, "code_information": [ { "code": "55150011720", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Amputate lower leg at knee", "code_information": [ { "code": "27598", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24436.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 44340.52, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 44340.52, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Amputate metacarpal bone", "code_information": [ { "code": "26910", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7262.93, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13178.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13178.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Amputation follow-up surgery", "code_information": [ { "code": "25909", "type": "HCPCS" }, { "code": "25931", "type": "HCPCS" }, { "code": "27884", "type": "HCPCS" }, { "code": "27886", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13888.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25200.45, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25200.45, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Amputation of finger/thumb", "code_information": [ { "code": "26951", "type": "HCPCS" }, { "code": "26952", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9204.18, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16701.13, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16701.13, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Amputation of foot at ankle", "code_information": [ { "code": "27889", "type": "HCPCS" }, { "code": "27888", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21587.94, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40153.87, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40153.87, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Amputation of forearm", "code_information": [ { "code": "25905", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16780.75, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30448.93, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30448.93, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Amputation of toe", "code_information": [ { "code": "28820", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8113.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14721.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14721.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Amputation thru metatarsal", "code_information": [ { "code": "28805", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16256.61, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29497.87, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29497.87, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Amputation toe & metatarsal", "code_information": [ { "code": "28810", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9034.15, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16392.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16392.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ANAGRELIDE HCL 0.5 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "13668045301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ANAGRELIDE HCL 1 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "13668046201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ANAKINRA 100 MG/0.67ML IV SOSY", "drug_information": { "unit": "0.670000", "type": "UN" }, "code_information": [ { "code": "66658023407", "type": "NDC" } ], "standard_charges": [ { "minimum": 194.2, "maximum": 1158.0, "gross_charge": 689.15, "discounted_cash": 379.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 399.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 376.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 598.18, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.54, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 330.79, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 412.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 412.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 647.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 606.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 585.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.62, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 647.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 539.6, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 376.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 547.87, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 606.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 399.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 376.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ANAKINRA 100 MG/0.67ML SC SOSY", "drug_information": { "unit": "0.670000", "type": "UN" }, "code_information": [ { "code": "66658023407_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 194.2, "maximum": 647.8, "gross_charge": 689.15, "discounted_cash": 379.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 399.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 376.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 551.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 583.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.54, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 330.79, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 412.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 412.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 647.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 606.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 585.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.62, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 647.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 539.6, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 376.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 547.87, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 606.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 399.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 376.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Anal sp inf pmp w/reprg&fill", "code_information": [ { "code": "62369", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 221.06, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.75, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1993.92, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3618.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3618.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ANALGESIC BALM 10-15 % EX CREA", "drug_information": { "unit": "85.000000", "type": "GR" }, "code_information": [ { "code": "41167006003", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.38, "maximum": 4.61, "gross_charge": 4.9, "discounted_cash": 2.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.43, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.35, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.38, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.33, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Analyze sp inf pump w/reprog", "code_information": [ { "code": "62368", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 221.06, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 684.48, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1242.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1242.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Analyze spine infus pump", "code_information": [ { "code": "62367", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 221.06, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1235.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2241.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2241.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ANASTROZOLE 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687011221", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ANGIOTENSIN II ACETATE 2.5 MG/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68547050102", "type": "NDC" } ], "standard_charges": [ { "minimum": 1369.55, "maximum": 4568.4, "gross_charge": 4860.0, "discounted_cash": 2673.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2818.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2653.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3888.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4116.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1414.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2332.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2911.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2906.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4568.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4276.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1369.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4131.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3645.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1712.18, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3304.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4568.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3805.38, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2653.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3863.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3645.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4276.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2818.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2653.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ANIDULAFUNGIN 100 MG IV SOLR", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "00049011628", "type": "NDC" } ], "standard_charges": [ { "minimum": 66.49, "maximum": 221.79, "gross_charge": 235.95, "discounted_cash": 129.77, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 199.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.66, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.26, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.49, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.13, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.45, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ANIDULAFUNGIN 50 MG IV SOLR", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "00049011428", "type": "NDC" } ], "standard_charges": [ { "minimum": 27.7, "maximum": 92.4, "gross_charge": 98.3, "discounted_cash": 54.07, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.61, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.18, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.7, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.73, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.63, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.84, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.97, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.73, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ankle arthroscopy/surgery", "code_information": [ { "code": "29891", "type": "HCPCS" }, { "code": "29892", "type": "HCPCS" }, { "code": "29894", "type": "HCPCS" }, { "code": "29895", "type": "HCPCS" }, { "code": "29897", "type": "HCPCS" }, { "code": "29898", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18359.55, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33313.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33313.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Anl sp inf pmp w/mdreprg&fil", "code_information": [ { "code": "62370", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 221.06, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.75, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2055.15, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3729.11, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3729.11, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Anoscopy", "code_information": [ { "code": "46615", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7121.19, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12921.56, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12921.56, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Anoscopy and biopsy", "code_information": [ { "code": "46606", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 869.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6155.47, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11169.2, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11169.2, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Anoscopy remove lesion", "code_information": [ { "code": "46610", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4612.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8370.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8370.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Antepartum manipulation", "code_information": [ { "code": "59412", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3972.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7209.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7209.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Anterior colporrhaphy", "code_information": [ { "code": "57240", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3638.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13937.85, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25290.47, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3638.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25290.47, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ANTI-THYMOCYTE GLOB (RABBIT) 25 MG IV SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "58468008001", "type": "NDC" } ], "standard_charges": [ { "minimum": 522.38, "maximum": 2605.68, "gross_charge": 2772.0, "discounted_cash": 1524.6, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1607.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 522.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2217.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2347.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 806.65, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1330.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1660.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1657.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2605.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2439.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 781.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2356.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2079.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 976.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1884.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2605.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2170.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 705.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2203.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2079.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2439.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1607.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 522.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTI-THYMOCYTE GLOB (RABBIT) 25 MG IV SOLR (MIXTURE USE)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "58468008001_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 522.38, "maximum": 2605.68, "gross_charge": 2772.0, "discounted_cash": 1524.6, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1607.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 522.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2217.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2347.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 806.65, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1330.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1660.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1657.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2605.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2439.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 781.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2356.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2079.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 976.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1884.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2605.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2170.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 705.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2203.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2079.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2439.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1607.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 522.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTICOAGULANT SODIUM CITRATE 46.7 % VI CONC", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "23731603003", "type": "NDC" } ], "standard_charges": [ { "minimum": 84.54, "maximum": 1158.0, "gross_charge": 300.0, "discounted_cash": 165.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 260.4, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 264.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.54, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 255.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 234.9, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 264.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEM FACTOR RECOMB (RFVIII) 1000 UNITS IV KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00026378555_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.85, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEM FACTOR RECOMB (RFVIII) 1000 UNITS IV KIT|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00026378555", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.66, "maximum": 2.19, "gross_charge": 2.33, "discounted_cash": 1.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.68, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.12, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.66, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.58, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.82, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEM FACTOR RECOMB (RFVIII) 801-1240 UNITS IV SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00944284310_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.85, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 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"HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEM FACTOR RECOMB (RFVIII) 801-1240 UNITS IV SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00944284310", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.85, "maximum": 2.85, "gross_charge": 3.03, "discounted_cash": 1.67, "setting": "inpatient", "payers_information": [ { 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"standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.07, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", 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{ "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHIL FACTOR (RAHF-PFM) 2000 UNITS IV SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00944304510_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.85, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHIL FACTOR (RAHF-PFM) 2000 UNITS IV SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00944304510", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.85, "maximum": 2.86, "gross_charge": 3.04, "discounted_cash": 1.67, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.46, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.86, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.07, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.38, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHIL FACTOR (RAHF-PFM) 500 UNITS IV SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00944305202_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.85, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHIL FACTOR (RAHF-PFM) 500 UNITS IV SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00944305202", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.74, "maximum": 2.47, "gross_charge": 2.63, "discounted_cash": 1.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.53, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.77, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.26, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.79, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.06, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.53, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR 1000 UNITS IV SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00944394402_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.64, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.86, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR 1000 UNITS IV SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00944394402", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.64, "maximum": 2.9, "gross_charge": 3.08, "discounted_cash": 1.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.9, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.87, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.86, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR 1700 UNITS IV SOLR", "drug_information": { "unit": "1.000000", "type": "F2" }, "code_information": [ { "code": "00944394602_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.64, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, 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88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR 1700 UNITS IV SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "F2" }, "code_information": [ { "code": "00944394602", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.55, "maximum": 1.82, "gross_charge": 1.94, "discounted_cash": 1.07, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 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"N/A", "standard_charge_dollar": 0.93, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.52, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.86, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR RAHF-PAF (XYNTHA)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "58394001401_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR RAHF-PAF (XYNTHA)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "58394001401", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.6, "maximum": 2.0, "gross_charge": 2.13, "discounted_cash": 1.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.62, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.02, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.45, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.67, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.69, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR VIII (KOATE DVI)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00944394402_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.64, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.86, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR VIII (KOATE DVI)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00944394402_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.64, "maximum": 2.9, "gross_charge": 3.08, "discounted_cash": 1.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.9, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.87, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.86, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR VIII RECOMBINANT (ADVATE)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00944305302_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.85, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR VIII RECOMBINANT (ADVATE)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00944305302", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.85, "maximum": 3.06, "gross_charge": 3.26, "discounted_cash": 1.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.95, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.92, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.15, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.22, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.55, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.59, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR VIII RECOMBINANT (KOGENATE FS)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00026378555_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.85, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR VIII RECOMBINANT (KOGENATE FS)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00026378555_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.66, "maximum": 2.19, "gross_charge": 2.33, "discounted_cash": 1.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.35, "standard_charge_percentage": 58.0, "methodology": 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"standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.66, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.58, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.82, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR-FVIII (ALPHANATE) IV SYRINGE", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68516461802_6", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.67, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR-FVIII (ALPHANATE) IV SYRINGE|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68516461802", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.62, "maximum": 2.07, "gross_charge": 2.2, "discounted_cash": 1.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.06, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.62, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.72, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR-VWF (ALPHANATE)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68516461802_7", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.67, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR-VWF (ALPHANATE) IV SYRINGE", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68516461802_8", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.67, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR-VWF (ALPHANATE) IV SYRINGE|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68516461802_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.62, "maximum": 2.07, "gross_charge": 2.2, "discounted_cash": 1.21, "setting": "inpatient", 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"standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.06, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.62, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.72, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR-VWF (ALPHANATE)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68516461802_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.62, "maximum": 2.07, "gross_charge": 2.2, "discounted_cash": 1.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.06, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.62, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.72, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR-VWF 1000 UNITS IV SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68516461802_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.67, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR-VWF 1000 UNITS IV SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68516461802_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.62, "maximum": 2.07, "gross_charge": 2.2, "discounted_cash": 1.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.06, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.62, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", 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"standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.03, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR-VWF 250-600 UNITS IV SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63833061502", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.75, "maximum": 2.5, "gross_charge": 2.66, "discounted_cash": 1.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.77, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.81, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.03, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR-VWF 500 UNITS IV SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68516461701_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.67, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR-VWF 500 UNITS IV SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68516461701", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.58, "maximum": 1.95, "gross_charge": 2.07, "discounted_cash": 1.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.99, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.55, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", 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"percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": 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charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR-VWF 500-1200 UNITS IV SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63833061602", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.59, "maximum": 1.96, "gross_charge": 2.08, "discounted_cash": 1.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.21, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.61, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.59, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.63, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.03, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.21, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIINHIBITOR COAGULANT CMPLX 1000 UNITS IV SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64193042402_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.28, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIINHIBITOR COAGULANT CMPLX 1000 UNITS IV SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64193042402", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.19, "maximum": 3.98, "gross_charge": 4.23, "discounted_cash": 2.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.31, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIINHIBITOR COAGULANT CMPLX 2500 UNITS IV SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64193042502_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.28, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIINHIBITOR COAGULANT CMPLX 2500 UNITS IV SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64193042502", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.11, "maximum": 3.69, "gross_charge": 3.93, "discounted_cash": 2.16, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.89, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.11, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.38, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.67, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTITHROMBIN III HUMAN (THROMBATE III)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "13533060612_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.1, "maximum": 4590.2, "gross_charge": 4883.19, "discounted_cash": 2685.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2832.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3906.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4136.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1421.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.93, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2925.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2920.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4590.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4297.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1376.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4150.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3662.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1720.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3320.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4590.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3823.54, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3882.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3662.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4297.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2832.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTITHROMBIN III HUMAN (THROMBATE III)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "13533060612", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.1, "maximum": 4524.4, "gross_charge": 4813.19, "discounted_cash": 2647.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2791.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3850.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4076.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1400.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2310.33, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2883.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2878.29, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4524.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4235.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1356.36, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4091.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3609.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1695.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3272.97, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4524.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3768.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3826.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3609.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4235.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2791.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTITHYMOCYTE GLOBULIN (RABBIT) SKIN TEST", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "58468008001_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 522.38, "maximum": 2605.68, "gross_charge": 2772.0, "discounted_cash": 1524.6, 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"additional_payer_notes": "N/A", "standard_charge_dollar": 2439.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 781.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2356.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2079.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 976.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1884.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2605.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2170.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 705.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 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(RABBIT) SKIN TEST (1:10 DILUTION) VIAL", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "58468008001_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 522.38, "maximum": 2605.68, "gross_charge": 2772.0, "discounted_cash": 1524.6, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1607.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 522.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2217.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { 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"payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 705.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2203.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2079.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2439.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1607.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 522.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTITHYMOCYTE GLOBULIN (RABBIT) SKIN TEST (1:100 DILUTION) VIAL", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "58468008001_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 522.38, "maximum": 2605.68, "gross_charge": 2772.0, "discounted_cash": 1524.6, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1607.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 522.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2217.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2347.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 806.65, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1330.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1660.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1657.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2605.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2439.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 781.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2356.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2079.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 976.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1884.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2605.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2170.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 705.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2203.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2079.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2439.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1607.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 522.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIVENIN LATRODECTUS MACTANS IJ KIT", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "00006542402", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.52, "maximum": 1158.0, "gross_charge": 69.28, "discounted_cash": 38.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.14, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.25, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.52, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.11, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.25, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "APIXABAN 2.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00003089331", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "APIXABAN 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00003089431", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Appendectomy", "code_information": [ { "code": "44950", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4599.32, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3406.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17403.83, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31579.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4599.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31579.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Appl mltpln uni ext fixj sys", "code_information": [ { "code": "20692", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10741.2, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19490.08, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19490.08, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Appl unipln uni ext fixj sys", "code_information": [ { "code": "20690", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18416.71, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33417.43, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33417.43, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "APRACLONIDINE HCL 0.5 % OP SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "61314066505", "type": "NDC" } ], "standard_charges": [ { "minimum": 26.75, "maximum": 89.23, "gross_charge": 94.93, "discounted_cash": 52.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.62, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.57, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.23, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.54, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.75, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.55, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.23, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.33, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.54, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "APRACLONIDINE HCL 1 % OP SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "82667020001", "type": "NDC" } ], "standard_charges": [ { "minimum": 42.46, "maximum": 141.64, "gross_charge": 150.68, "discounted_cash": 82.87, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.85, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.33, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.46, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.98, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "APREPITANT 125 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00781232368", "type": "NDC" } ], "standard_charges": [ { "minimum": 161.64, "maximum": 539.17, "gross_charge": 573.59, "discounted_cash": 315.47, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 332.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 313.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 458.87, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 485.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.91, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 275.32, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 343.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 343.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 539.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 504.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.64, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 487.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 202.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 390.04, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 539.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 449.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 313.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 456.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 504.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 332.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 313.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "APREPITANT 40 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00781232151", "type": "NDC" } ], "standard_charges": [ { "minimum": 56.82, "maximum": 189.53, "gross_charge": 201.63, "discounted_cash": 110.9, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.67, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.78, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.82, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.11, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.88, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "APREPITANT 80 & 125 MG PO MISC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00006386203", "type": "NDC" } ], "standard_charges": [ { "minimum": 691.69, "maximum": 2307.28, "gross_charge": 2454.55, "discounted_cash": 1350.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1423.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1340.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1963.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2079.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 714.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1178.18, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1470.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2307.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2160.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.69, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2086.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1840.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 864.74, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1669.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2307.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1921.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1340.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1951.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1840.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2160.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1423.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1340.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "APREPITANT 80 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00781232268", "type": "NDC" } ], "standard_charges": [ { "minimum": 122.86, "maximum": 409.83, "gross_charge": 435.99, "discounted_cash": 239.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 252.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 348.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 369.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.87, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 261.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 260.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 409.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 383.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.86, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 370.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 326.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 296.47, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 409.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.38, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 346.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 326.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 383.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 252.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AQUADEKS PO CHEW", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R5891401460", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AQUADEKS PO SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "58204000404", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AQUANIL SKIN CLEANSER EX LOTN", "drug_information": { "unit": "480.000000", "type": "UN" }, "code_information": [ { "code": "00096072416", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.67, "maximum": 25.6, "gross_charge": 27.23, "discounted_cash": 14.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.07, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.67, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.52, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AQUAPHOR ADVANCED THERAPY EX OINT", "drug_information": { "unit": "396.000000", "type": "GR" }, "code_information": [ { "code": "72140063608", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.48, "maximum": 38.31, "gross_charge": 40.75, "discounted_cash": 22.41, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.86, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.48, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.36, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.71, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AQUAPHOR EX OINT", "drug_information": { "unit": "50.000000", "type": "GR" }, "code_information": [ { "code": "72140045231", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.81, "maximum": 12.72, "gross_charge": 13.53, "discounted_cash": 7.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.94, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.49, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.81, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.77, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.59, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Aqueous shunt eye w/graft", "code_information": [ { "code": "66180", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3803.22, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2817.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8866.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16087.64, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3803.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16087.64, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Aqueous shunt eye w/o graft", "code_information": [ { "code": "66179", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3803.22, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2817.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3868.25, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7019.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3803.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7019.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARFORMOTEROL TARTRATE 15 MCG/2ML IN NEBU", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "69097016864", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARGATROBAN 250 MG/2.5ML IV SOLN", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "00143967401", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.69, "maximum": 566.18, "gross_charge": 602.32, "discounted_cash": 331.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.69, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 481.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.28, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 289.11, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 360.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 360.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 566.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 530.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 169.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.2, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 409.58, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 566.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 471.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 478.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 530.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.69, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ARGATROBAN 250 MG/250 ML DRIP (STRAIGHT DRUG) (MULTI-GPI)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00000198801", "type": "NDC" } ], "standard_charges": [ { "minimum": 613.31, "maximum": 2045.82, "gross_charge": 2176.4, "discounted_cash": 1197.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1262.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1188.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1741.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1843.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 633.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1044.67, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1303.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1301.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2045.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1915.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 613.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1849.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1632.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 766.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1479.95, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2045.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1704.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1188.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1730.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1632.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1915.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1262.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1188.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARGATROBAN 50 MG/50ML IV SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "25021041450", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.69, "maximum": 197.06, "gross_charge": 209.64, "discounted_cash": 115.3, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.69, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.71, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.63, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.86, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.56, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.15, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.69, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ARGATROBAN 50 MG/50ML IV SOLN (MULTI-GPI)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "65219042950", "type": "NDC" } ], "standard_charges": [ { "minimum": 107.6, "maximum": 358.91, "gross_charge": 381.82, "discounted_cash": 210.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 208.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 305.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 323.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.11, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.27, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 228.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 228.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.6, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 324.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 286.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.52, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.64, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 298.97, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 208.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 303.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 286.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 208.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARGININE 10% (FOR AMMONUL PANEL) LOADING DOSE", "drug_information": { "unit": "300.000000", "type": "UN" }, "code_information": [ { "code": "00009043601_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 46.47, "maximum": 1158.0, "gross_charge": 164.9, "discounted_cash": 90.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.13, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.99, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.15, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.47, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.13, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARGININE 10% (FOR AMMONUL PANEL) MAINTENANCE INFUSION", "drug_information": { "unit": "300.000000", "type": "UN" }, "code_information": [ { "code": "00009043601_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 46.47, "maximum": 1158.0, "gross_charge": 164.9, "discounted_cash": 90.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.13, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.99, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.15, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.47, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.13, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARGININE HCL (DIAGNOSTIC) 10 % IV SOLN", "drug_information": { "unit": "300.000000", "type": "UN" }, "code_information": [ { "code": "00009043601", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.18, "maximum": 1158.0, "gross_charge": 100.0, "discounted_cash": 55.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.8, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARGININE HCL 10 % (IV FOR PO)", "drug_information": { "unit": "300.000000", "type": "UN" }, "code_information": [ { "code": "00009043601_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.18, "maximum": 1158.0, "gross_charge": 100.0, "discounted_cash": 55.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.8, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARGININE HCL 10% IV SYRINGE (PEDS)", "drug_information": { "unit": "300.000000", "type": "UN" }, "code_information": [ { "code": "00009043601_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 46.47, "maximum": 1158.0, "gross_charge": 164.9, "discounted_cash": 90.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.13, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.99, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.15, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.47, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.13, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARGININE HCL 1MEQ/ML ORAL SOLUTION", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "P0009043624", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 1158.0, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARIPIPRAZOLE 1 MG/ML PO SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "66689073505", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.28, "maximum": 4.26, "gross_charge": 4.53, "discounted_cash": 2.49, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.32, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.08, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.55, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARIPIPRAZOLE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268008915", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARIPIPRAZOLE 10 MG PO TBDP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "43598073330", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.74, "maximum": 9.15, "gross_charge": 9.73, "discounted_cash": 5.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.83, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.67, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.43, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.62, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARIPIPRAZOLE 15 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268009012", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARIPIPRAZOLE 15 MG PO TBDP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "43598073430", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.74, "maximum": 9.15, "gross_charge": 9.73, "discounted_cash": 5.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.83, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.67, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.43, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.62, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARIPIPRAZOLE 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687015721", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.13, "maximum": 10.43, "gross_charge": 11.1, "discounted_cash": 6.11, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.33, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.91, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.55, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.69, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARIPIPRAZOLE 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687020221", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.24, "maximum": 14.15, "gross_charge": 15.05, "discounted_cash": 8.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.22, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.24, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.3, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.23, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARIPIPRAZOLE 30 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687021321", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.44, "maximum": 14.82, "gross_charge": 15.77, "discounted_cash": 8.67, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.59, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.57, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.44, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.56, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARIPIPRAZOLE 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268008815", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARIPIPRAZOLE ER 300 MG IM PRSY", "drug_information": { "unit": "1.500000", "type": "UN" }, "code_information": [ { "code": "59148004580", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.86, "maximum": 5185.5, "gross_charge": 5516.49, "discounted_cash": 3034.07, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3199.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.86, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4413.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4672.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1605.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2647.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3304.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3298.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5185.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4854.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1554.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4689.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4137.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1943.46, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3751.21, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5185.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4319.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4385.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4137.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4854.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3199.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.86, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ARIPIPRAZOLE ER 400 MG IM PRSY", "drug_information": { "unit": "400.000000", "type": "ME" }, "code_information": [ { "code": "59148007280", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.86, "maximum": 6914.02, "gross_charge": 7355.34, "discounted_cash": 4045.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4266.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.86, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5884.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6229.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2140.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3530.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4405.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4398.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6914.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6472.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2072.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6252.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5516.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2591.29, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5001.63, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6914.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5759.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5847.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5516.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6472.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4266.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.86, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ARIPIPRAZOLE ER 400 MG IM SRER", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "59148001971", "type": "NDC" } ], "standard_charges": [ { "minimum": 2072.73, "maximum": 6914.02, "gross_charge": 7355.34, "discounted_cash": 4045.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4266.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4016.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5884.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6229.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2140.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3530.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4405.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4398.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6914.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6472.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2072.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6252.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5516.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2591.29, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5001.63, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6914.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5759.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4016.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5847.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5516.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6472.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4266.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4016.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARIPIPRAZOLE LAUROXIL ER 1064 MG/3.9ML IM PRSY", "drug_information": { "unit": "3.900000", "type": "UN" }, "code_information": [ { "code": "65757040403", "type": "NDC" } ], "standard_charges": [ { "minimum": 2853.55, "maximum": 9518.57, "gross_charge": 10126.14, "discounted_cash": 5569.38, "setting": 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"additional_generic_notes": "" } ] }, { "description": "ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6ML IM PRSY", "drug_information": { "unit": "1.600000", "type": "UN" }, "code_information": [ { "code": "65757040103", "type": "NDC" } ], "standard_charges": [ { "minimum": 1182.71, "maximum": 3945.18, "gross_charge": 4197.0, "discounted_cash": 2308.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2434.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2291.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3357.6, 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1810.28, "maximum": 6038.55, "gross_charge": 6423.99, "discounted_cash": 3533.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3725.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3507.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5139.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5441.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed 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"methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5653.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1810.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5460.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4817.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2263.17, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4368.31, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6038.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5029.98, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3507.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { 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"methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARIPIPRAZOLE LAUROXIL ER 882 MG/3.2ML IM PRSY", "drug_information": { "unit": "3.200000", "type": "UN" }, "code_information": [ { "code": "65757040303", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.76, "maximum": 7890.33, "gross_charge": 8393.97, "discounted_cash": 4616.68, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4868.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 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"N/A", "standard_charge_dollar": 5019.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7890.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7386.69, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2365.42, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7134.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6295.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2957.2, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5707.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7890.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6572.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6673.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6295.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7386.69, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4868.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ARMODAFINIL 150 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63459021530", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.26, "maximum": 77.59, "gross_charge": 82.54, "discounted_cash": 45.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.03, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.02, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.62, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.13, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.63, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARMODAFINIL 250 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63459022530", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.26, "maximum": 77.59, "gross_charge": 82.54, "discounted_cash": 45.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.03, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.02, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.62, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.13, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.63, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARMODAFINIL 50 MG PO TABS", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "R6345920530", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.27, "maximum": 44.26, "gross_charge": 47.09, "discounted_cash": 25.9, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.02, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARSENIC TRIOXIDE 10 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "68382099710", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.93, "maximum": 104.54, "gross_charge": 111.21, "discounted_cash": 61.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.18, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.62, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.41, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ARTEMETHER-LUMEFANTRINE 20-120 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078056845", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.58, "maximum": 11.96, "gross_charge": 12.72, "discounted_cash": 7.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.11, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.58, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.65, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Artery-vein autograft", "code_information": [ { "code": "36825", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3984.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2951.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21102.09, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38290.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3984.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38290.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Artery-vein nonautograft", "code_information": [ { "code": "36830", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3984.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2951.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19057.06, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34579.34, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3984.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34579.34, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARTESUNATE 110 MG IV SOLR", "drug_information": { "unit": "11.000000", "type": "UN" }, "code_information": [ { "code": "73607001111", "type": "NDC" } ], "standard_charges": [ { "minimum": 3813.08, "maximum": 12719.3, "gross_charge": 13531.17, "discounted_cash": 7442.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7848.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7388.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10824.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11460.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3937.57, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6494.96, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8105.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8091.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12719.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11907.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3813.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11501.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10148.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4767.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9201.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12719.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10594.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7388.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10757.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10148.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11907.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7848.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7388.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Arthr si jt opn b1grf instrm", "code_information": [ { "code": "27280", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 27953.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 50722.71, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 50722.71, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrd ant ntrbd min dsc crv", "code_information": [ { "code": "22554", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 45790.27, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 83114.12, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 83114.12, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrd ant ntrbd min dsc lum", "code_information": [ { "code": "22558", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 70474.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 127877.38, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 127877.38, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrd ant ntrbdy cervical", "code_information": [ { "code": "22551", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 42276.3, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 77071.07, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 77071.07, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrd cmbn 1ntrspc lumbar", "code_information": [ { "code": "22633", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13555.31, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10040.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 68983.51, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 125171.79, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13555.31, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 125171.79, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrd pst tq 1ntrspc lum", "code_information": [ { "code": "22630", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13555.31, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10040.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 64874.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 117716.05, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13555.31, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 117716.05, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrd pst tq 1ntrspc lumbar", "code_information": [ { "code": "22612", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13555.31, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10040.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 61569.33, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 111718.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13555.31, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 111718.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrd si jt perq/min nvas", "code_information": [ { "code": "27279", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13555.31, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10040.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 31250.5, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 56704.56, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13555.31, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 56704.56, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrt elbw capsl exc rls", "code_information": [ { "code": "24006", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11824.64, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21603.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21603.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrt elbw jt expl bx rmvl", "code_information": [ { "code": "24101", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9079.28, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16474.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16474.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARTIFICIAL TEARS 83-15 % OP OINT", "drug_information": { "unit": "4.000000", "type": "GR" }, "code_information": [ { "code": "63736014308", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASCORBIC ACID 25000 MG/50ML IV SOLN", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "67157010150", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASCORBIC ACID 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904052361", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASENAPINE MALEATE 5 MG SL SUBL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "42794001610", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.88, "maximum": 6.27, "gross_charge": 6.67, "discounted_cash": 3.67, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.94, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.88, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.54, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.22, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASPARAGINASE ERWINIA CHRY-RYWN 10 MG/0.5ML IM SOLN", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "68727090003", "type": "NDC" } ], "standard_charges": [ { "minimum": 4210.09, "maximum": 14043.6, "gross_charge": 14940.0, "discounted_cash": 8217.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8665.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8157.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11952.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12654.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4347.54, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7171.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8949.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8934.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14043.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13147.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4210.09, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12699.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11205.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5263.36, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10159.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14043.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11698.02, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8157.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11877.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11205.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13147.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8665.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8157.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Aspir/inj thyroid cyst", "code_information": [ { "code": "60300", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 518.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5840.51, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10597.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10597.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Aspirate pleura w/ imaging", "code_information": [ { "code": "32555", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 455.72, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3467.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6291.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 455.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6291.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Aspirate pleura w/o imaging", "code_information": [ { "code": "32554", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 455.72, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6409.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11629.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 455.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11629.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Aspirate/inj ganglion cyst", "code_information": [ { "code": "20612", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 217.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8533.67, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15488.09, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15488.09, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Aspiration orbital contents", "code_information": [ { "code": "67415", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13390.86, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24297.94, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24297.94, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASPIRIN 0.1 MG/ML FOR DESENSITIZATION", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "C6373943401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASPIRIN 1 MG/ML FOR DESENSITIZATION", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "C6373943401_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASPIRIN 10 MG/ML ORAL SUSPENSION", "drug_information": { "unit": "8.100000", "type": "UN" }, "code_information": [ { "code": "08252000057", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASPIRIN 300 MG RE SUPP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00574703412", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASPIRIN 325 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "66553000101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASPIRIN 325 MG PO TBEC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1013512601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASPIRIN 8.1 MG/ML ORAL SUSPENSION", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "08252000056", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.83, "maximum": 106.17, "gross_charge": 112.95, "discounted_cash": 62.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.87, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.22, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.83, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.81, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.44, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASPIRIN 80 MG SUPPOSITORY", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "P0904404073", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 1158.0, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASPIRIN 80 MG SUPPOSITORY (NICU)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "P0904404073_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 1158.0, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASPIRIN 81 MG PO CHEW", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "66553000201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASPIRIN 81 MG PO CHEW (NICU)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "66553000201_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASPIRIN 81 MG PO TBEC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R7139986271", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASPIRIN-DIPYRIDAMOLE ER 25-200 MG PO CP12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "65162059606", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Assess cyst contrast inject", "code_information": [ { "code": "49424", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 992.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1800.01, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1800.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATAZANAVIR SULFATE 200 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "65862071260", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.9, "maximum": 6.33, "gross_charge": 6.73, "discounted_cash": 3.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.38, "standard_charge_percentage": 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"standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.9, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.58, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.27, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATAZANAVIR SULFATE 300 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00093552856", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.72, "maximum": 22.43, "gross_charge": 23.86, "discounted_cash": 13.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.94, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.45, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.29, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.22, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.68, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATAZANAVIR-COBICISTAT 300-150 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00003364111", "type": "NDC" } ], "standard_charges": [ { "minimum": 34.15, "maximum": 113.9, "gross_charge": 121.17, "discounted_cash": 66.64, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.88, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.33, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATENOLOL 10 MG/ML SUSPENSION", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "P5107975920", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATENOLOL 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079068520", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATENOLOL 12.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0378021801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATENOLOL 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079075920", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total 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"percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": 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"All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATEZOLIZUMAB 1200 MG/20ML IV SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "50242091701", "type": "NDC" } ], "standard_charges": [ { "minimum": 47.09, "maximum": 30805.93, "gross_charge": 32772.27, "discounted_cash": 18024.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19007.92, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26217.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27758.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9536.73, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15730.69, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19630.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30805.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28839.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9235.23, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27856.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24579.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11545.67, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22285.14, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30805.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25660.69, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24579.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28839.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19007.92, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ATOMOXETINE HCL 10 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "55111051930", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATOMOXETINE HCL 18 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64980037403", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATOMOXETINE HCL 25 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687056721", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.19, "maximum": 3.97, "gross_charge": 4.22, "discounted_cash": 2.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.87, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATOMOXETINE HCL 40 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687032625", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.83, "maximum": 6.09, "gross_charge": 6.48, "discounted_cash": 3.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.89, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.11, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.83, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.28, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.07, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATOMOXETINE HCL 60 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00093354656", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.57, "maximum": 8.56, "gross_charge": 9.11, "discounted_cash": 5.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.29, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.65, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.57, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.21, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.19, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATOMOXETINE HCL 80 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "55111056330", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATORVASTATIN CALCIUM 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084009701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATORVASTATIN CALCIUM 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904629161", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATORVASTATIN CALCIUM 40 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084009901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATORVASTATIN CALCIUM 80 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084059025", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATOVAQUONE 750 MG/5ML PO SUSP", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "60687053478", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.86, "maximum": 22.87, "gross_charge": 24.33, "discounted_cash": 13.38, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.08, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.68, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.86, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.57, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.54, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.05, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATOVAQUONE-PROGUANIL HCL 250-100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68001024515", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.92, "maximum": 6.42, "gross_charge": 6.83, "discounted_cash": 3.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.99, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.01, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.12, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.12, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.01, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATOVAQUONE-PROGUANIL HCL 62.5-25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378416001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.35, "maximum": 4.5, "gross_charge": 4.79, "discounted_cash": 2.63, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.39, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.3, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.35, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.26, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATRACURIUM BESYLATE 50 MG/5ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "55150021605", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATRAPRO DERMAL SPRAY EX LIQD", "drug_information": { "unit": "236.000000", "type": "UN" }, "code_information": [ { "code": "23710006508", "type": "NDC" } ], "standard_charges": [ { "minimum": 176.01, "maximum": 587.11, "gross_charge": 624.58, "discounted_cash": 343.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 362.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 499.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 529.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.75, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 374.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 373.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 587.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 549.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.01, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 530.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.04, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 424.71, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 587.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 489.05, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 496.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 549.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 362.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATRAPRO HYDROGEL EX GEL", "drug_information": { "unit": "113.000000", "type": "GR" }, "code_information": [ { "code": "23710006004", "type": "NDC" } ], "standard_charges": [ { "minimum": 155.01, "maximum": 517.08, "gross_charge": 550.08, "discounted_cash": 302.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 319.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 440.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 465.92, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.07, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 264.04, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 329.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 328.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 517.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 484.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.01, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 467.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 412.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 374.05, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 517.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.71, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 437.31, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 412.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 484.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 319.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATROPINE 0.4 MG/ML 20ML (BULK CHARGE)", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "16729051243", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, 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billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": 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"methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 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"standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATROPINE SULFATE 0.4 MG/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00517100425", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", 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"payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATROPINE SULFATE 1 % OP SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "60219174903", "type": "NDC" } ], "standard_charges": [ { "minimum": 24.02, "maximum": 80.12, "gross_charge": 85.23, "discounted_cash": 46.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.19, "standard_charge_percentage": 85.0, "methodology": 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94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.02, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.92, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.74, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.92, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATROPINE SULFATE 1 MG/10ML IJ SOSY", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "76329334001_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { 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"standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATROPINE SULFATE 1 MG/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00517100125", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATROPINE SULFATE 1% OP SOLN 2ML (BULK CHARGE)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "60219174802", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.68, "maximum": 65.66, "gross_charge": 69.85, "discounted_cash": 38.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.53, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.61, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.69, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.53, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATROPINE SULFATE 1.2 MG/3ML IV SOSY", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "69374093503", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATROPINE SULFATE 8 MG/20ML IJ SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "16729051243_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Attach bladder/urethra", "code_information": [ { "code": "51841", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 42584.57, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 80313.78, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 80313.78, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Augmentation cheek bone", "code_information": [ { "code": "21270", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 66768.75, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 121153.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 121153.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Augmentation lower jaw bone", "code_information": [ { "code": "21125", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 27279.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 49506.03, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 49506.03, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Augmentation of facial bones", "code_information": [ { "code": "21208", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 83655.97, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 151795.11, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 151795.11, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Autgrft implnt knee w/scope", "code_information": [ { "code": "29866", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14781.44, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26821.17, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26821.17, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Autochondrocyte implant knee", "code_information": [ { "code": "27412", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17055.47, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30947.45, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30947.45, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Av fistula revision", "code_information": [ { "code": "36833", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3984.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2951.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18231.25, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33080.93, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3984.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33080.93, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Av fistula revision open", "code_information": [ { "code": "36832", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3984.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2951.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16294.66, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29566.94, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3984.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29566.94, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Av fuse uppr arm basilic", "code_information": [ { "code": "36819", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3984.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2951.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": 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"fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22458.74, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Av fusion direct any site", "code_information": [ { "code": "36821", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2320.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1718.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13578.57, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24638.54, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2320.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24638.54, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AVACINCAPTAD PEGOL 2 MG/0.1ML IZ SOLN", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "82829000201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1775.34, "maximum": 5922.0, "gross_charge": 6300.0, 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"Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5544.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1775.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5355.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4725.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2219.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4284.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5922.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4932.9, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3439.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5008.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4725.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5544.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3654.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3439.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AVACOPAN 10 MG PO CAPS", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "73556016801", "type": "NDC" } ], "standard_charges": [ { "minimum": 233.19, "maximum": 777.84, "gross_charge": 827.49, "discounted_cash": 455.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 479.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 661.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 700.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.8, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 397.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 495.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 494.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 777.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 728.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 233.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 703.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 620.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 291.52, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 562.69, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 777.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 647.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 657.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 620.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 728.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 479.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AVALGLUCOSIDASE ALFA-NGPT 100 MG IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "58468042601", "type": "NDC" } ], "standard_charges": [ { "minimum": 42.45, "maximum": 5230.17, "gross_charge": 5564.01, "discounted_cash": 3060.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3227.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.45, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4451.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4712.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1619.13, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2670.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3332.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3327.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5230.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4896.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1567.94, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4729.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4173.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1960.2, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3783.53, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5230.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4356.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.31, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4423.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4173.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4896.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3227.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.45, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "AVEENO MOISTURIZING EX BAR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08137003623", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.65, "maximum": 5.5, "gross_charge": 5.85, "discounted_cash": 3.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.81, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.15, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.65, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.06, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.58, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.15, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AVEENO SOOTHING BATH TREATMENT EX PACK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08137003640", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AYR SALINE NASAL NA GEL", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "00225052547", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.55, "maximum": 11.84, "gross_charge": 12.6, "discounted_cash": 6.93, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.67, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZACITIDINE 100 MG IJ SUSR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "71288011530", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.57, "maximum": 61.95, "gross_charge": 65.9, "discounted_cash": 36.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.63, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.57, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.22, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.81, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.6, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZACITIDINE CHEMO SC SYRINGE", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "71288011530_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.57, "maximum": 61.95, "gross_charge": 65.9, "discounted_cash": 36.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.63, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.57, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.22, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZATHIOPRINE 10MG/ML ORAL SUSPENSION", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "08252000159", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZATHIOPRINE 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084022901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZATHIOPRINE SODIUM 100 MG IJ SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00143956601", "type": "NDC" } ], "standard_charges": [ { "minimum": 128.68, "maximum": 657.05, "gross_charge": 698.99, "discounted_cash": 384.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 405.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 559.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 592.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.41, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 335.52, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 418.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 418.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 657.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 615.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.98, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 594.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 524.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.25, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.31, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 657.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 547.31, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 173.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 555.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 524.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 615.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 405.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "AZELAIC ACID 15 % EX GEL", "drug_information": { "unit": "50.000000", "type": "GR" }, "code_information": [ { "code": "68462062652", "type": "NDC" } ], "standard_charges": [ { "minimum": 95.71, "maximum": 319.27, "gross_charge": 339.65, "discounted_cash": 186.81, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 185.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 271.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 287.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.84, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 319.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 298.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.71, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 288.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 319.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 265.95, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 185.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 270.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 298.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 185.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZELASTINE HCL 0.05 % OP SOLN", "drug_information": { "unit": "6.000000", "type": "UN" }, "code_information": [ { "code": "70069009101", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZELASTINE HCL 0.1 % NA SOLN", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "60505083305", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.07, "maximum": 23.59, "gross_charge": 25.1, "discounted_cash": 13.81, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.07, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.84, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.07, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.65, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZELASTINE-FLUTICASONE 137-50 MCG/ACT NA SUSP", "drug_information": { "unit": "23.000000", "type": "GR" }, "code_information": [ { "code": "00037024523", "type": "NDC" } ], "standard_charges": [ { "minimum": 133.75, "maximum": 446.15, "gross_charge": 474.63, "discounted_cash": 261.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 275.29, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 379.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 402.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 227.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 283.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 446.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 417.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.75, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 403.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 355.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.21, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 322.75, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 446.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 371.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 377.33, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 355.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 417.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 275.29, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZITHROMYCIN 1 % OP SOLN", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "17478030703", "type": "NDC" } ], "standard_charges": [ { "minimum": 198.6, "maximum": 662.47, "gross_charge": 704.76, "discounted_cash": 387.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 408.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 563.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 596.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.09, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 338.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 422.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 421.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 662.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 620.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.6, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 599.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 528.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 248.29, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 479.24, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 662.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 551.83, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 560.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 528.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 620.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 408.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZITHROMYCIN 100 MG/5ML PO SUSR", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "00093202723", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.58, "maximum": 21.95, "gross_charge": 23.35, "discounted_cash": 12.84, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.79, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.21, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.58, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.28, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZITHROMYCIN 200 MG/5ML PO SUSR", "drug_information": { "unit": "22.500000", "type": "UN" }, "code_information": [ { "code": "00093202694", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.17, "maximum": 23.92, "gross_charge": 25.45, "discounted_cash": 14.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.41, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.22, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.17, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.97, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.31, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.93, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.23, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZITHROMYCIN 250 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687074201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZTREONAM 1 G IJ SOLR", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "63323040120", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.08, "maximum": 46.97, "gross_charge": 49.97, "discounted_cash": 27.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.54, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.99, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.98, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZTREONAM 1 G IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323040120_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.08, "maximum": 46.97, "gross_charge": 49.97, "discounted_cash": 27.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.54, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.99, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.98, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZTREONAM 2 G IJ SOLR", "drug_information": { "unit": "8.000000", "type": "UN" }, "code_information": [ { "code": "63323040220", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.76, "maximum": 95.93, "gross_charge": 102.05, "discounted_cash": 56.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.98, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.95, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.39, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZTREONAM 2 G IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323040220_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.76, "maximum": 95.93, "gross_charge": 102.05, "discounted_cash": 56.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.98, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.95, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.39, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "B COMPLEX PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1184506011", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BACITRA-NEOMYCIN-POLYMYXIN-HC 1 % OP OINT", "drug_information": { "unit": "4.000000", "type": "GR" }, "code_information": [ { "code": "24208078555", "type": "NDC" } ], "standard_charges": [ { "minimum": 48.78, "maximum": 162.71, "gross_charge": 173.1, "discounted_cash": 95.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.09, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.78, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.71, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.54, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BACITRACIN 500 UNIT/GM OP OINT", "drug_information": { "unit": "4.000000", "type": "GR" }, "code_information": [ { "code": "00574402235", "type": "NDC" } ], "standard_charges": [ { "minimum": 165.97, "maximum": 553.64, "gross_charge": 588.98, "discounted_cash": 323.94, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 321.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 471.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 498.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.39, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.71, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 352.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 352.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 553.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.97, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 500.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 441.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 400.51, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 553.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 461.17, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 321.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 441.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 321.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BACITRACIN ZINC 500 UNIT/GM EX OINT", "drug_information": { "unit": "29.000000", "type": "GR" }, "code_information": [ { "code": "51672207502", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.95, "maximum": 19.83, "gross_charge": 21.1, "discounted_cash": 11.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.14, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.13, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.95, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.43, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.35, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.52, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BACITRACIN ZINC 500 UNIT/GM EX OINT 15GM (BULK CHARGE)", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "51672207501", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.03, "maximum": 6.77, "gross_charge": 7.2, "discounted_cash": 3.96, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.46, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.03, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.54, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BACITRACIN-NEOMYCIN-POLYMIXIN EX OINT 0.9GM (BULK CHARGE)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904880567", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BACITRACIN-POLYMYXIN B 500-10000 UNIT/GM OP OINT", "drug_information": { "unit": "4.000000", "type": "GR" }, "code_information": [ { "code": "24208055555", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BACLOFEN 0.05 MG/ML IT SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "70257056255", "type": "NDC" } ], "standard_charges": [ { "minimum": 24.66, "maximum": 82.25, "gross_charge": 87.5, "discounted_cash": 48.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.83, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.51, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BACLOFEN 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268010615", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BACLOFEN 10 MG/20ML IT SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "67457056220", "type": "NDC" } ], "standard_charges": [ { "minimum": 95.32, "maximum": 552.92, "gross_charge": 588.21, "discounted_cash": 323.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.16, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 498.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.34, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 352.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 351.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 552.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 517.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 499.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 441.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 399.98, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 552.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 460.57, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 467.63, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 441.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 517.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.16, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BACLOFEN 10 MG/5ML IT SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "70257056102", "type": "NDC" } ], "standard_charges": [ { "minimum": 95.32, "maximum": 575.75, "gross_charge": 612.5, "discounted_cash": 336.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 355.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 490.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.24, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 366.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 366.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 575.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 539.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.6, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 520.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 459.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 416.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 575.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 479.59, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 459.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 539.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 355.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BACLOFEN 10000 MCG/20ML IT SOSY", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "66794015501", "type": "NDC" } ], "standard_charges": [ { "minimum": 95.32, "maximum": 587.27, "gross_charge": 624.75, "discounted_cash": 343.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 362.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 499.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 529.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.8, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.88, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 374.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 373.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 587.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 549.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.05, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 531.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.1, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 424.83, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 587.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 489.18, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 496.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 549.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 362.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BACLOFEN 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687082601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BACLOFEN 20000 MCG/20ML IT SOSY", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "66794015601", "type": "NDC" } ], "standard_charges": [ { "minimum": 95.32, "maximum": 1323.14, "gross_charge": 1407.6, "discounted_cash": 774.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 816.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1126.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1192.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 409.61, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 675.65, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 843.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 841.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1323.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1238.69, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 396.66, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1196.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1055.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 495.9, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 957.17, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1323.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1102.15, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1119.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1055.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1238.69, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 816.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BACLOFEN 25 MG/5ML PO SUSP", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "52536060011", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.36, "maximum": 4.52, "gross_charge": 4.81, "discounted_cash": 2.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.31, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.36, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.27, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BACLOFEN 40 MG/20ML IT SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "67457056420", "type": "NDC" } ], "standard_charges": [ { "minimum": 95.32, "maximum": 2071.99, "gross_charge": 2204.24, "discounted_cash": 1212.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1278.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1763.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1866.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 641.43, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1058.04, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1320.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1318.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2071.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1939.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 621.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1873.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1653.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 776.55, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1498.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2071.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1725.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1752.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1653.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1939.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1278.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BACLOFEN 40000 MCG/20ML IT SOSY", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "66794015701", "type": "NDC" } ], "standard_charges": [ { "minimum": 95.32, "maximum": 2489.04, "gross_charge": 2647.92, "discounted_cash": 1456.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1535.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2118.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2242.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 770.54, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1271.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1586.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1583.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2489.04, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2330.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 746.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2250.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1985.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 932.86, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1800.59, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2489.04, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2073.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2105.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1985.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2330.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1535.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BACLOFEN 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268010515", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BACLOFEN 5 MG/ML PO SUSP (PTL)", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "08252000076", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BACLOFEN 50 MCG/ML IT SOSY", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "66794015101", "type": "NDC" } ], "standard_charges": [ { "minimum": 62.09, "maximum": 207.1, "gross_charge": 220.32, "discounted_cash": 121.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.11, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.75, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.09, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.62, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.82, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.51, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BACTERIOSTATIC WATER(BENZ ALC) IJ SOLN", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "00409397703", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BALSALAZIDE DISODIUM 750 MG PO CAPS", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00054007928", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.44, "maximum": 4.81, "gross_charge": 5.12, "discounted_cash": 2.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.46, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.44, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.8, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.48, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.01, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BARICITINIB 1 MG PO TABS (COVID-19 USE ONLY)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00002473230", "type": "NDC" } ], "standard_charges": [ { "minimum": 68.88, "maximum": 229.77, "gross_charge": 244.44, "discounted_cash": 134.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.13, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.33, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.88, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.22, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.4, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.33, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BARICITINIB 2 MG PO TABS (COVID-19 USE ONLY)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00002418230", "type": "NDC" } ], "standard_charges": [ { "minimum": 68.88, "maximum": 229.77, "gross_charge": 244.44, "discounted_cash": 134.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.13, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.33, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.88, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.22, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.4, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.33, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BASILIXIMAB 10 MG IV SOLR", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "00078039361", "type": "NDC" } ], "standard_charges": [ { "minimum": 2505.47, "maximum": 9315.56, "gross_charge": 9910.17, "discounted_cash": 5450.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5747.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2505.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7928.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8393.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2883.86, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4756.88, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5936.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5926.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9315.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8720.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2792.69, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8423.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7432.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3491.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6738.92, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9315.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7759.66, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3382.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7878.59, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7432.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8720.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5747.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2505.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BASILIXIMAB 20 MG IV SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00078033184", "type": "NDC" } ], "standard_charges": [ { "minimum": 2505.47, "maximum": 12226.62, "gross_charge": 13007.04, "discounted_cash": 7153.87, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7544.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2505.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10405.63, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11016.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3785.05, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6243.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7791.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7778.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12226.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11446.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3665.38, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11055.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9755.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4582.38, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8844.79, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12226.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10184.51, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3382.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10340.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9755.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11446.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7544.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2505.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BCG LIVE 50 MG IS SUSR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00052060202", "type": "NDC" } ], "standard_charges": [ { "minimum": 151.71, "maximum": 506.07, "gross_charge": 538.37, "discounted_cash": 296.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 312.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { 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total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 506.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 473.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.71, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 457.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 403.78, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.67, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 366.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 506.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 421.54, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { 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"percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BECAPLERMIN 0.01 % EX GEL", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "50484081015", "type": "NDC" } ], "standard_charges": [ { "minimum": 1041.1, "maximum": 3472.8, "gross_charge": 3694.47, "discounted_cash": 2031.96, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2142.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2017.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2955.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3129.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1075.09, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1773.35, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2212.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2209.29, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3472.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3251.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1041.1, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3140.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2770.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1301.56, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2512.24, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3472.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2892.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2017.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2937.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2770.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3251.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2142.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2017.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BECLOMETHASONE DIPROP HFA 40 MCG/ACT IN AERB", "drug_information": { "unit": "11.000000", "type": "GR" }, "code_information": [ { "code": "59310030240", "type": "NDC" } ], "standard_charges": [ { "minimum": 272.66, "maximum": 909.5, "gross_charge": 967.55, "discounted_cash": 532.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 561.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 528.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 774.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 819.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 281.56, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 464.42, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 579.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 578.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 909.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 851.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 272.66, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 822.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 725.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 340.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 657.93, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 909.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 757.59, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 528.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 769.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 725.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 851.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 561.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 528.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BECLOMETHASONE DIPROP HFA 80 MCG/ACT IN AERB", "drug_information": { "unit": "11.000000", "type": "GR" }, "code_information": [ { "code": "59310030480", "type": "NDC" } ], "standard_charges": [ { "minimum": 365.07, "maximum": 1217.77, "gross_charge": 1295.5, "discounted_cash": 712.53, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 751.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 707.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1036.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1097.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 376.99, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 621.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 776.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 774.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1217.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1140.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 365.07, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1101.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 971.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 456.4, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 880.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1217.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1014.38, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 707.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1029.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 971.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1140.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 751.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 707.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BECLOMETHASONE DIPROPIONATE 0.5 MG/ML SUSPENSION (PTL)", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "00000000024", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BELATACEPT 250 MG IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00003037113", "type": "NDC" } ], "standard_charges": [ { "minimum": 1093.25, "maximum": 3646.75, "gross_charge": 3879.52, "discounted_cash": 2133.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2250.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2118.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3103.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3285.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1128.94, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1862.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2323.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2319.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3646.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3413.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1093.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3297.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2909.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1366.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2638.07, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3646.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3037.66, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2118.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3084.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2909.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3413.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2250.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2118.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BELIMUMAB 120 MG IV SOLR", "drug_information": { "unit": "1.500000", "type": "UN" }, "code_information": [ { "code": "49401010101", "type": "NDC" } ], "standard_charges": [ { "minimum": 29.57, "maximum": 2339.85, "gross_charge": 2489.2, "discounted_cash": 1369.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1443.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1991.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2108.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 724.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1491.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1488.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2339.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2190.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 701.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2115.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1866.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 876.95, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1692.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2339.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1949.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1978.91, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1866.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2190.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1443.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BELIMUMAB 400 MG IV SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "49401010201", "type": "NDC" } ], "standard_charges": [ { "minimum": 29.57, "maximum": 5849.3, "gross_charge": 6222.66, "discounted_cash": 3422.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3609.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4978.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5270.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1810.79, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2986.88, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3727.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3721.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5849.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5475.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1753.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5289.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4667.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2192.24, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4231.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5849.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4872.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4947.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4667.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5475.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3609.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BELINOSTAT 500 MG IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "72893000201", "type": "NDC" } ], "standard_charges": [ { "minimum": 27.35, "maximum": 6925.55, "gross_charge": 7367.61, "discounted_cash": 4052.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4273.21, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.35, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5894.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6240.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2143.97, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3536.45, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All 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billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6262.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5525.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2595.61, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5009.97, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 6483.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4273.21, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.35, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BELLADONNA ALKALOIDS-OPIUM 16.2-30 MG RE SUPP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00574704512", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.05, "maximum": 46.86, "gross_charge": 49.85, "discounted_cash": 27.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.51, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.93, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.05, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.56, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BELLADONNA ALKALOIDS-OPIUM 16.2-60 MG RE SUPP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00574704012", "type": "NDC" } ], "standard_charges": [ { "minimum": 17.08, "maximum": 56.96, "gross_charge": 60.6, "discounted_cash": 33.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.63, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.09, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.21, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENAZEPRIL HCL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268011015", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENAZEPRIL HCL 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268011115", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENAZEPRIL HCL 40 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268011215", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENAZEPRIL HCL 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268010915", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENAZEPRIL-HYDROCHLOROTHIAZIDE 20-12.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00185021101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENDAMUSTINE HCL 100 MG/4ML IV SOLN", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "63459034804", "type": "NDC" } ], "standard_charges": [ { "minimum": 1785.18, "maximum": 5954.82, "gross_charge": 6334.92, "discounted_cash": 3484.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3674.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3458.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5067.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5365.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1843.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3040.76, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3794.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3788.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5954.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5574.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1785.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5384.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4751.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2231.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4307.75, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5954.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4960.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3458.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5036.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4751.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5574.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3674.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3458.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENZOCAINE 20 % MT GEL", "drug_information": { "unit": "30.000000", "type": "GR" }, "code_information": [ { "code": "00283087131", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.76, "maximum": 15.87, "gross_charge": 16.88, "discounted_cash": 9.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.91, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.1, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.95, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.48, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.22, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENZOCAINE 20 % MT SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00283061026", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.46, "maximum": 21.56, "gross_charge": 22.94, "discounted_cash": 12.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.68, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.01, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENZOCAINE 20 % RE OINT", "drug_information": { "unit": "28.000000", "type": "GR" }, "code_information": [ { "code": "63736003751", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.48, "maximum": 8.27, "gross_charge": 8.8, "discounted_cash": 4.84, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.22, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.48, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.1, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.98, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.89, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENZOCAINE 20% LIDOCAINE 8% TETRACAINE 8% CREAM", "drug_information": { "unit": "30.000000", "type": "GR" }, "code_information": [ { "code": "08252000067", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.47, "maximum": 61.62, "gross_charge": 65.55, "discounted_cash": 36.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.08, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.46, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.47, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.33, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENZOCAINE-MENTHOL 20-0.5 % EX AERO", "drug_information": { "unit": "85.000000", "type": "GR" }, "code_information": [ { "code": "16864068003", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.35, "maximum": 11.19, "gross_charge": 11.9, "discounted_cash": 6.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.71, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.35, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.93, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.19, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.93, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENZOYL PEROXIDE 10 % EX GEL", "drug_information": { "unit": "60.000000", "type": "GR" }, "code_information": [ { "code": "45802030896", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.0, "maximum": 30.03, "gross_charge": 31.95, "discounted_cash": 17.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.53, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.34, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.12, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.26, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.73, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.02, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.12, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.53, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENZOYL PEROXIDE 10 % EX LIQD", "drug_information": { "unit": "148.000000", "type": "GR" }, "code_information": [ { "code": "71399923605", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.09, "maximum": 13.63, "gross_charge": 14.5, "discounted_cash": 7.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.96, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.09, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.86, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.53, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENZOYL PEROXIDE 5 % EX GEL", "drug_information": { "unit": "60.000000", "type": "GR" }, "code_information": [ { "code": "71399947806", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.29, "maximum": 17.65, "gross_charge": 18.78, "discounted_cash": 10.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.01, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.29, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.62, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.77, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.7, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENZOYL PEROXIDE 5 % EX LIQD", "drug_information": { "unit": "148.000000", "type": "GR" }, "code_information": [ { "code": "35573045391", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.55, "maximum": 11.83, "gross_charge": 12.58, "discounted_cash": 6.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.66, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.04, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.43, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.55, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.85, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENZOYL PEROXIDE 7 % EX LIQD", "drug_information": { "unit": "473.000000", "type": "UN" }, "code_information": [ { "code": "42546014516", "type": "NDC" } ], "standard_charges": [ { "minimum": 68.69, "maximum": 229.13, "gross_charge": 243.75, "discounted_cash": 134.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 206.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 214.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.69, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.75, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.86, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 214.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENZTROPINE MESYLATE 0.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084038101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENZTROPINE MESYLATE 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084038801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENZTROPINE MESYLATE 1 MG/ML IJ SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00143972905", "type": "NDC" } ], "standard_charges": [ { "minimum": 29.26, "maximum": 97.61, "gross_charge": 103.84, "discounted_cash": 57.11, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.38, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.61, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.31, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.38, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENZTROPINE MESYLATE 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084038901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENZYLPENICILLOYL POLYLYSINE 0.25 ML ID SOLN", "drug_information": { "unit": "0.250000", "type": "UN" }, "code_information": [ { "code": "49471000105", "type": "NDC" } ], "standard_charges": [ { "minimum": 150.97, "maximum": 1158.0, "gross_charge": 535.72, "discounted_cash": 294.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 310.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 292.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 465.0, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.89, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 257.15, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 320.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 320.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 503.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 471.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.97, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 455.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 401.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 364.29, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 503.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 419.47, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 292.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 425.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 401.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 471.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 310.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 292.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BERACTANT IN NACL 25-0.9 MG/ML-% INTRATRACHEA SUSP", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "00074104004", "type": "NDC" } ], "standard_charges": [ { "minimum": 205.28, "maximum": 1158.0, "gross_charge": 728.46, "discounted_cash": 400.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 422.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 397.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 632.3, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 211.98, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.66, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 436.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 435.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 684.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 641.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 619.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 546.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 256.64, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 495.35, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 684.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 570.38, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 397.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 579.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 546.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 641.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 422.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 397.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BESIFLOXACIN HCL 0.6 % OP SUSP", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "24208044605", "type": "NDC" } ], "standard_charges": [ { "minimum": 202.46, "maximum": 675.34, "gross_charge": 718.45, "discounted_cash": 395.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 416.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 392.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 574.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 608.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.07, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 344.86, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 429.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 675.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 632.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 202.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 610.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 538.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 253.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 488.55, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 675.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 562.55, "standard_charge_percentage": 78.0, "methodology": 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"standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 392.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BETAMETHASONE DIPROPIONATE 0.05 % EX CREA", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "00168005515", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.93, "maximum": 49.8, "gross_charge": 52.98, "discounted_cash": 29.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.42, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.43, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.93, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BETAMETHASONE DIPROPIONATE 0.05 % EX LOTN", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "00168005760", "type": "NDC" } ], "standard_charges": [ { "minimum": 16.84, "maximum": 56.17, "gross_charge": 59.75, "discounted_cash": 32.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.39, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.68, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.84, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.05, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.63, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BETAMETHASONE DIPROPIONATE 0.05 % EX OINT", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "00472038115", "type": "NDC" } ], "standard_charges": [ { "minimum": 16.23, "maximum": 54.13, "gross_charge": 57.58, "discounted_cash": 31.67, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.76, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.64, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.23, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.29, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.09, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BETAMETHASONE DIPROPIONATE AUG 0.05 % EX CREA", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "51672131001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.54, "maximum": 5.15, "gross_charge": 5.48, "discounted_cash": 3.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.59, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.63, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.54, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.73, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BETAMETHASONE DIPROPIONATE AUG 0.05 % EX GEL", "drug_information": { "unit": "50.000000", "type": "GR" }, "code_information": [ { "code": "51672130903", "type": "NDC" } ], "standard_charges": [ { "minimum": 57.13, "maximum": 190.57, "gross_charge": 202.73, "discounted_cash": 111.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.99, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.31, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.42, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.86, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.74, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BETAMETHASONE DIPROPIONATE AUG 0.05 % EX LOTN", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "00168026760", "type": "NDC" } ], "standard_charges": [ { "minimum": 53.65, "maximum": 178.98, "gross_charge": 190.4, "discounted_cash": 104.72, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.41, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.39, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.65, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.47, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BETAMETHASONE DIPROPIONATE AUG 0.05 % EX OINT", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "66993089715", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.58, "maximum": 51.96, "gross_charge": 55.28, "discounted_cash": 30.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.09, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.53, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.58, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.59, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.28, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00517072001", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.68, "maximum": 78.99, "gross_charge": 84.03, "discounted_cash": 46.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.45, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.33, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.14, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BETAMETHASONE VALERATE 0.1 % EX CREA", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "00168004015", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.88, "maximum": 22.96, "gross_charge": 24.43, "discounted_cash": 13.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.11, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.88, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.61, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.61, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BETAMETHASONE VALERATE 0.1 % EX LOTN", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "00168004160", "type": "NDC" } ], "standard_charges": [ { "minimum": 21.38, "maximum": 71.33, "gross_charge": 75.88, "discounted_cash": 41.73, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.08, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.42, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.38, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BETAMETHASONE VALERATE 0.1 % EX OINT", "drug_information": { "unit": "45.000000", "type": "GR" }, "code_information": [ { "code": "00472037145", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.22, "maximum": 60.77, "gross_charge": 64.65, "discounted_cash": 35.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.81, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.22, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BETHANECHOL CHLORIDE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687068901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BETHANECHOL CHLORIDE 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00832051201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BEVACIZUMAB (AVASTIN) INTRAVITREAL INJ (1.25 MG/0.05 ML)", "drug_information": { "unit": "0.050000", "type": "UN" }, "code_information": [ { "code": "50242006001", "type": "NDC" } ], "standard_charges": [ { "minimum": 763.57, "maximum": 2547.02, "gross_charge": 2709.6, "discounted_cash": 1490.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1571.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1479.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2167.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2295.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 788.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1300.61, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1623.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1620.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2547.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2384.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 763.57, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2303.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2032.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 954.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1842.53, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2547.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2121.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1479.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2154.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2032.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2384.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1571.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1479.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BEVACIZUMAB 100 MG/4ML IV SOLN", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "50242006001_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 763.57, "maximum": 2547.02, "gross_charge": 2709.6, "discounted_cash": 1490.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1571.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1479.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2167.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2295.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 788.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1300.61, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1623.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1620.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2547.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2384.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 763.57, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2303.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2032.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 954.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1842.53, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2547.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2121.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1479.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2154.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2032.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2384.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1571.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1479.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BEVACIZUMAB 400 MG/16ML IV SOLN", "drug_information": { "unit": "16.000000", "type": "UN" }, "code_information": [ { "code": "50242006101", "type": "NDC" } ], "standard_charges": [ { "minimum": 2290.7, "maximum": 7641.07, "gross_charge": 8128.8, "discounted_cash": 4470.84, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4714.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4438.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6503.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6885.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2365.48, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3901.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4869.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4861.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7641.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7153.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2290.7, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6909.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6096.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2863.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5527.58, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7641.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6364.85, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4438.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6462.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6096.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7153.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4714.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4438.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BEVACIZUMAB-AWWB 100 MG/4ML IV SOLN", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "55513020601", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.52, "maximum": 2493.9, "gross_charge": 2653.08, "discounted_cash": 1459.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1538.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.52, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2122.46, 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Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1989.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 934.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1804.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2493.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2077.36, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1989.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2334.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1538.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.52, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BEVACIZUMAB-AWWB 400 MG/16ML IV SOLN", "drug_information": { "unit": "16.000000", "type": "UN" }, "code_information": [ { "code": "55513020701", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.52, "maximum": 7481.52, "gross_charge": 7959.06, "discounted_cash": 4377.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4616.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.52, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6367.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6741.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2316.09, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3820.35, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6765.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5969.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2803.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5412.16, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7481.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6231.94, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6327.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5969.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7003.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4616.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.52, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BEVACIZUMAB-BVZR 100 MG/4ML IV SOLN", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "00069031501", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.88, "maximum": 2022.43, "gross_charge": 2151.52, "discounted_cash": 1183.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1247.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1721.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1822.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 626.09, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1032.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1288.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1286.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2022.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1893.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 606.3, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1828.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1613.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 757.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1463.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2022.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1684.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1710.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1613.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1893.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1247.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BEVACIZUMAB-BVZR 25 MG/ML INTRALESIONAL INJ", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "00069031501_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.88, "maximum": 2022.43, "gross_charge": 2151.52, "discounted_cash": 1183.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1247.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1721.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1822.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 626.09, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1032.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1288.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1286.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2022.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1893.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 606.3, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1828.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1613.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 757.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1463.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2022.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1684.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1710.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1613.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1893.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1247.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BEVACIZUMAB-BVZR 400 MG/16ML IV SOLN", "drug_information": { "unit": "16.000000", "type": "UN" }, "code_information": [ { "code": "00069034201", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.88, "maximum": 6067.26, "gross_charge": 6454.53, "discounted_cash": 3549.99, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3743.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5163.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5466.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1878.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3098.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3866.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3859.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6067.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5679.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1818.89, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5486.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4840.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2273.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4389.08, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6067.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5053.9, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5131.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4840.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5679.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3743.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BICALUTAMIDE 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "47335048583", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BICTEGRAVIR-EMTRICITAB-TENOFOV 50-200-25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "61958250101", "type": "NDC" } ], "standard_charges": [ { "minimum": 126.96, "maximum": 423.51, "gross_charge": 450.54, "discounted_cash": 247.8, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 261.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 360.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 381.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.11, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.26, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 269.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 269.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 423.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 396.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.96, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 382.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 306.37, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 423.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 352.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 396.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 261.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biliary endo perq dx w/speci", "code_information": [ { "code": "47552", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4599.32, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3406.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23652.07, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42922.24, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4599.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42922.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biliary endoscopy thru skin", "code_information": [ { "code": "47554", "type": "HCPCS" }, { "code": "47555", "type": "HCPCS" }, { "code": "47556", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1926.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 22610.66, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41027.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41027.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BIMATOPROST 0.01 % OP SOLN", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "00023320503", "type": "NDC" } ], "standard_charges": [ { "minimum": 224.45, "maximum": 748.71, "gross_charge": 796.5, "discounted_cash": 438.08, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 461.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 434.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 637.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 674.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 382.32, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 477.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 476.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 748.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 700.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 677.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 597.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 280.61, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 541.62, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 748.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 623.66, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 434.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 633.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 597.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 700.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 461.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 434.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BIMATOPROST 10 MCG IO IMPL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00023965201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1679.81, "maximum": 5603.34, "gross_charge": 5961.0, "discounted_cash": 3278.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3457.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3254.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4768.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5048.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1734.65, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2861.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3570.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3564.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5603.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5245.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1679.81, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5066.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4470.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2100.06, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4053.48, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5603.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4667.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3254.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4739.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4470.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5245.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3457.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3254.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy abdominal mass", "code_information": [ { "code": "49180", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4671.33, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8476.2, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8476.2, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy arm/elbow soft tissue", "code_information": [ { "code": "24065", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8008.41, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14531.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14531.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy eye muscle", "code_information": [ { "code": "67346", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2779.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2058.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8938.39, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18090.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2779.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18090.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy eyelid & lid margin", "code_information": [ { "code": "67810", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 220.34, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1264.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2295.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2295.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy finger joint lining", "code_information": [ { "code": "26110", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6284.82, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11403.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11403.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy muscle perq needle", "code_information": [ { "code": "20206", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4154.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7537.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7537.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of breast open", "code_information": [ { "code": "19101", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2822.56, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2090.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5573.86, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10113.86, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2822.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10113.86, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of cervix", "code_information": [ { "code": "57500", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 641.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10639.2, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19886.23, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 641.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19886.23, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of cervix w/scope", "code_information": [ { "code": "57455", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 224.22, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1197.34, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2172.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2172.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of cornea", "code_information": [ { "code": "65410", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5077.23, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9212.72, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9212.72, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of external ear", "code_information": [ { "code": "69100", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 171.17, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1815.35, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3294.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3294.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of external ear canal", "code_information": [ { "code": "69105", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1091.85, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4179.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7583.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7583.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of eyelid lining", "code_information": [ { "code": "68100", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8575.93, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15561.16, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15561.16, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of floor of mouth", "code_information": [ { "code": "41108", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5750.63, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10434.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10434.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of heart lining", "code_information": [ { "code": "93505", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2320.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1718.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7780.21, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14117.31, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2320.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14117.31, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of lip", "code_information": [ { "code": "40490", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 171.17, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1433.44, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2601.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2601.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of neck/chest", "code_information": [ { "code": "21550", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13756.22, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24960.94, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24960.94, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of nerve", "code_information": [ { "code": "64795", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 40428.71, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 73358.57, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 73358.57, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of ovary(s)", "code_information": [ { "code": "58900", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18671.01, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33878.85, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33878.85, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of penis", "code_information": [ { "code": "54100", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4434.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8046.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8046.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of prostate", "code_information": [ { "code": "55700", "type": "HCPCS" }, { "code": "55705", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1118.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4651.36, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8439.98, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8439.98, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of rectum", "code_information": [ { "code": "45100", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7288.11, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13227.98, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13227.98, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of salivary gland", "code_information": [ { "code": "42400", "type": "HCPCS" }, { "code": "42405", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1091.85, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2623.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4761.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4761.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of soft tissues", "code_information": [ { "code": "27040", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6486.06, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11769.06, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11769.06, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of tear gland", "code_information": [ { "code": "68510", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5964.99, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10823.56, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10823.56, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of tear sac", "code_information": [ { "code": "68525", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10308.85, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18705.59, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18705.59, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of testis", "code_information": [ { "code": "54500", "type": "HCPCS" }, { "code": "54505", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11837.67, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21479.65, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21479.65, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of throat", "code_information": [ { "code": "42800", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1091.85, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12772.25, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23175.45, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23175.45, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of thyroid", "code_information": [ { "code": "60100", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 518.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3412.48, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6192.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6192.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of tongue", "code_information": [ { "code": "41100", "type": "HCPCS" }, { "code": "41105", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 278.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9266.83, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17655.89, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17655.89, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of upper nose/throat", "code_information": [ { "code": "42804", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18660.65, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33860.03, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33860.03, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of uterus lining", "code_information": [ { "code": "58100", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 148.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1038.62, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1884.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1884.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of vagina", "code_information": [ { "code": "57100", "type": "HCPCS" }, { "code": "57105", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6728.94, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12209.77, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 641.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12209.77, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of vulva/perineum", "code_information": [ { "code": "56605", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 641.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3483.9, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6321.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 641.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6321.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy roof of mouth", "code_information": [ { "code": "42100", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1091.85, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17921.78, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32519.35, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32519.35, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy shoulder tissues", "code_information": [ { "code": "23065", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9267.66, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16816.33, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16816.33, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy thigh soft tissues", "code_information": [ { "code": "27324", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17929.42, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33540.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33540.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy/removal lymph nodes", "code_information": [ { "code": "38500", "type": "HCPCS" }, { "code": "38510", "type": "HCPCS" }, { "code": "38520", "type": "HCPCS" }, { "code": "38525", "type": "HCPCS" }, { "code": "38530", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2822.56, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2090.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12271.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24431.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2822.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24431.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BIOTENE DRY MOUTH MT LIQD", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "R4858200440", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BIOTIN 1000 MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "54629398501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BIOTIN 5 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "40985027116", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BIOTIN 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "54022107501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BIOTIN 5 MG PO TBDP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "40093010118", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BISACODYL 10 MG RE SUPP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00574705050", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BISACODYL 10 MG/30ML RE ENEM", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00132070336", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.24, "maximum": 4.14, "gross_charge": 4.4, "discounted_cash": 2.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.55, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.11, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.24, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.55, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.99, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.55, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BISACODYL 5 MG PO TBEC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904640761", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BISMUTH SUBSALICYLATE 262 MG PO CHEW", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "46122070165", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BISMUTH SUBSALICYLATE 262 MG/15ML PO SUSP", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "00536128636", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BISOPROLOL FUMARATE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "29300012713", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BISOPROLOL FUMARATE 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "29300012613", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "16729027567", "type": "NDC" } ], "standard_charges": [ { "minimum": 54.81, "maximum": 182.84, "gross_charge": 194.51, "discounted_cash": 106.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.6, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.36, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.53, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.27, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BLEOMYCIN 9 UNITS/ML SYRINGE FOR CHEMOEMBOLIZATION", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "71288010610_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 34.41, "maximum": 114.77, "gross_charge": 122.1, "discounted_cash": 67.16, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.53, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.61, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.02, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.6, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BLEOMYCIN CHEMO OPHTHALMIC SYRINGE", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "08252000063", "type": "NDC" } ], "standard_charges": [ { "minimum": 33.51, "maximum": 111.79, "gross_charge": 118.93, "discounted_cash": 65.41, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.61, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.09, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.51, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.9, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.87, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BLEOMYCIN CHEMO SYRINGE", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "71288010610_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 34.41, "maximum": 114.77, "gross_charge": 122.1, "discounted_cash": 67.16, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.53, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.61, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.02, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.6, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BLEOMYCIN SULFATE 15 UNITS IJ SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "71288010610", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.68, "maximum": 48.97, "gross_charge": 52.1, "discounted_cash": 28.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.01, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BLINATUMOMAB 35 MCG IV SOLR", "drug_information": { "unit": "2.800000", "type": "UN" }, "code_information": [ { "code": "55513016001", "type": "NDC" } ], "standard_charges": [ { "minimum": 83.09, "maximum": 14509.35, "gross_charge": 15435.48, "discounted_cash": 8489.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8952.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12348.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13073.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4491.72, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7409.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9245.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9230.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14509.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13583.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4349.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13120.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11576.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5437.92, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10496.13, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14509.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12085.98, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12271.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11576.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13583.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8952.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Bone biopsy open deep", "code_information": [ { "code": "20245", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5113.09, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9277.78, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9277.78, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bone biopsy open superficial", "code_information": [ { "code": "20240", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5012.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9094.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9094.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bone biopsy trocar/ndl deep", "code_information": [ { "code": "20225", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5724.34, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10386.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10386.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bone biopsy trocar/ndl supfc", "code_information": [ { "code": "20220", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4486.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8140.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8140.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bone marrow harvest autolog", "code_information": [ { "code": "38232", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3453.44, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2558.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18908.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34310.62, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3453.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34310.62, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BONNEYS BLUE DYE 2%", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "08252043030", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.07, "maximum": 26.93, "gross_charge": 28.65, "discounted_cash": 15.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.34, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.75, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.07, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.48, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.43, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BORTEZOMIB 3.5 MG IJ SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "71288011810", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.77, "maximum": 42.58, "gross_charge": 45.3, "discounted_cash": 24.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.77, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.47, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BORTEZOMIB CHEMO IV SYRINGE", "drug_information": { "unit": "3.500000", "type": "UN" }, "code_information": [ { "code": "71288011810_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.77, "maximum": 42.58, "gross_charge": 45.3, "discounted_cash": 24.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.77, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.47, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BORTEZOMIB CHEMO SC SYRINGE", "drug_information": { "unit": "1.400000", "type": "UN" }, "code_information": [ { "code": "71288011810_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.77, "maximum": 42.58, "gross_charge": 45.3, "discounted_cash": 24.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.77, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.47, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BOSENTAN 125 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68382044714", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.57, "maximum": 35.27, "gross_charge": 37.52, "discounted_cash": 20.64, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.01, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.57, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.22, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.51, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.38, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BOSENTAN 6.25 MG/ML ORAL SUSPENSION", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "08252000080", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.35, "maximum": 41.19, "gross_charge": 43.82, "discounted_cash": 24.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.75, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.35, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.31, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BOSENTAN 62.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68382044614", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.27, "maximum": 34.24, "gross_charge": 36.43, "discounted_cash": 20.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.6, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.49, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.24, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.83, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.77, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.24, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.52, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BOSUTINIB 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00069013601", "type": "NDC" } ], "standard_charges": [ { "minimum": 588.88, "maximum": 1964.34, "gross_charge": 2089.72, "discounted_cash": 1149.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1212.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1140.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1671.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1769.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 608.11, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1003.07, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1251.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1249.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1964.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1838.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 588.88, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1776.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1567.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 736.21, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1421.01, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1964.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1636.25, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1140.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1661.33, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1567.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1838.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1212.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1140.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BOTULISM IMMUNE GLOBULIN HUMAN 100 MG IV SOLR", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "68403110006", "type": "NDC" } ], "standard_charges": [ { "minimum": 1158.0, "maximum": 42582.0, "gross_charge": 45300.0, "discounted_cash": 24915.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26274.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24733.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39320.4, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13182.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21744.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27134.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42582.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39864.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12765.54, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38505.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33975.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15959.19, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30804.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42582.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35469.9, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24733.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33975.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39864.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26274.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24733.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Brain canal shunt procedure", "code_information": [ { "code": "61070", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 510.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 378.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16379.03, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29766.83, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29766.83, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Breast augmentation w/implt", "code_information": [ { "code": "19325", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7053.35, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5224.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17483.86, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31724.75, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7053.35, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31724.75, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Breast reconstruction", "code_information": [ { "code": "19350", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2822.56, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2090.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18257.02, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33127.66, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2822.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33127.66, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Breast reduction", "code_information": [ { "code": "19318", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4806.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3560.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16860.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30594.18, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4806.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30594.18, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BRENTUXIMAB VEDOTIN 50 MG IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "51144005001", "type": "NDC" } ], "standard_charges": [ { "minimum": 130.96, "maximum": 33112.44, "gross_charge": 35226.0, "discounted_cash": 19374.3, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20431.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28180.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 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of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12410.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23953.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33112.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27581.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", 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"Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BREXPIPRAZOLE 3 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59148003913", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.3, "maximum": 104.41, "gross_charge": 111.07, "discounted_cash": 61.09, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs 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85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.13, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.53, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.97, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BRILLIANT BLUE G 0.025 % IO SOSY", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "68803072225", "type": "NDC" } ], "standard_charges": [ { "minimum": 138.08, "maximum": 1158.0, "gross_charge": 490.0, "discounted_cash": 269.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 267.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 425.32, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.59, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 460.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 431.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 416.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 367.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.63, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue 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billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 431.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 267.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BRIMONIDINE TARTRATE 0.1 % OP SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00023932105", "type": "NDC" } ], "standard_charges": [ { "minimum": 173.61, "maximum": 579.11, "gross_charge": 616.07, "discounted_cash": 338.84, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 357.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 492.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 521.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.28, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 295.71, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 369.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 368.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 579.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 542.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 173.61, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 523.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 462.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.04, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 418.93, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 579.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 482.38, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 489.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 462.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 542.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 357.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BRIMONIDINE TARTRATE 0.15 % OP SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "61314014405", "type": "NDC" } ], "standard_charges": [ { "minimum": 117.74, "maximum": 392.76, "gross_charge": 417.83, "discounted_cash": 229.81, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 228.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 334.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 353.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.59, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 249.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 392.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 367.69, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 355.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 313.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.2, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 392.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 327.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { 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"methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 228.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BRIMONIDINE TARTRATE 0.2 % OP SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "70069023101", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BRIMONIDINE TARTRATE-TIMOLOL 0.2-0.5 % OP SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00023921105", "type": "NDC" } ], "standard_charges": [ { "minimum": 182.26, "maximum": 607.96, "gross_charge": 646.77, "discounted_cash": 355.72, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 353.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 517.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 547.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.21, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 310.45, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 387.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 386.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 607.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 569.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 549.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 485.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 227.86, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 439.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 607.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 506.42, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 353.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 514.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 485.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 569.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 353.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BRIVARACETAM 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R5047437066", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.9, "maximum": 43.01, "gross_charge": 45.76, "discounted_cash": 25.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.32, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.96, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.9, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.83, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BRIVARACETAM 10 MG/ML PO SOLN", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "50474087015", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.64, "maximum": 25.49, "gross_charge": 27.12, "discounted_cash": 14.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.89, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.02, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.64, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.55, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BRIVARACETAM 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50474077009", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.28, "maximum": 50.98, "gross_charge": 54.23, "discounted_cash": 29.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BRIVARACETAM 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50474047009", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.28, "maximum": 50.98, "gross_charge": 54.23, "discounted_cash": 29.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BRIVARACETAM 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50474057066", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.28, "maximum": 50.98, "gross_charge": 54.23, "discounted_cash": 29.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BRIVARACETAM 50 MG/5ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "50474097075", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Brnchsc w/ther aspir 1st", "code_information": [ { "code": "31645", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1271.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 941.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13676.5, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24816.24, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1271.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24816.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BROMFENAC SODIUM (ONCE-DAILY) 0.09 % OP SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "72266014201", "type": "NDC" } ], "standard_charges": [ { "minimum": 24.97, "maximum": 83.28, "gross_charge": 88.6, "discounted_cash": 48.73, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.53, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.97, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.21, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.25, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.37, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BROMFENAC SODIUM 0.07 % OP SOLN", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "24208060203", "type": "NDC" } ], "standard_charges": [ { "minimum": 364.33, "maximum": 1215.31, "gross_charge": 1292.88, "discounted_cash": 711.08, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 749.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 705.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1034.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1095.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 376.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 620.58, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 774.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 773.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1215.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1137.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 364.33, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1098.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 969.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 455.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 879.16, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1215.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1012.33, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 705.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1027.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 969.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1137.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 749.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 705.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BROMOCRIPTINE MESYLATE 2.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0781532501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BROMOCRIPTINE MESYLATE 5 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378709693", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.79, "maximum": 5.97, "gross_charge": 6.35, "discounted_cash": 3.49, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.85, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.79, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.24, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.97, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronch ebus samplng 1/2 node", "code_information": [ { "code": "31652", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2717.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2013.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15314.58, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27788.54, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27788.54, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronch ebus samplng 3/> node", "code_information": [ { "code": "31653", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2717.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2013.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16102.59, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29218.42, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29218.42, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronch thermoplsty 1 lobe", "code_information": [ { "code": "31660", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18996.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34468.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34468.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronch thermoplsty 2/> lobes", "code_information": [ { "code": "31661", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14280.3, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25911.84, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25911.84, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronch w/balloon occlusion", "code_information": [ { "code": "31634", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17699.69, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32116.38, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32116.38, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronchial valve init insert", "code_information": [ { "code": "31647", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 34148.27, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 61962.74, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 61962.74, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronchial valve remov init", "code_information": [ { "code": "31648", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2717.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2013.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8105.21, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14707.04, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14707.04, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronchoscopy bronch stents", "code_information": [ { "code": "31636", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15011.42, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27238.48, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27238.48, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronchoscopy dilate w/stent", "code_information": [ { "code": "31631", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16718.35, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30335.81, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30335.81, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronchoscopy dilate/fx repr", "code_information": [ { "code": "31630", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2717.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2013.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8973.33, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16282.29, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16282.29, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronchoscopy revise stent", "code_information": [ { "code": "31638", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8368.74, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15185.24, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15185.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronchoscopy treat blockage", "code_information": [ { "code": "31641", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2717.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2013.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10722.21, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19455.69, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19455.69, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronchoscopy w/biopsy(s)", "code_information": [ { "code": "31625", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1271.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 941.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11804.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21419.68, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1271.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21419.68, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronchoscopy w/fb removal", "code_information": [ { "code": "31635", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1271.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 941.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10780.28, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19561.03, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1271.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19561.03, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronchoscopy w/markers", "code_information": [ { "code": "31626", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10298.27, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18686.38, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18686.38, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronchoscopy w/tumor excise", "code_information": [ { "code": "31640", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2717.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2013.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10897.53, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19773.76, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19773.76, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronchoscopy/lung bx each", "code_information": [ { "code": "31628", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2717.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2013.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14320.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25984.94, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25984.94, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronchoscopy/needle bx each", "code_information": [ { "code": "31629", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2717.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2013.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15685.94, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28462.41, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28462.41, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Brst rcnstj free flap", "code_information": [ { "code": "19364", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15971.94, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28981.37, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28981.37, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BSS IO SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "00065079515", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BSS IO SOLN 15ML (BULK CHARGE)", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "00065079515_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BSS PLUS IO SOLN", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00065080050", "type": "NDC" } ], "standard_charges": [ { "minimum": 52.59, "maximum": 1158.0, "gross_charge": 186.61, "discounted_cash": 102.64, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.98, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.57, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.59, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.74, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.89, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUDESONIDE 0.25 MG/2ML IN SUSP", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00487960101", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.15, "maximum": 7.16, "gross_charge": 7.62, "discounted_cash": 4.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.66, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.18, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.97, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUDESONIDE 0.5 MG/2ML IN SUSP", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "60687052483", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.01, "maximum": 6.71, "gross_charge": 7.14, "discounted_cash": 3.93, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.71, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.08, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.43, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.01, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.52, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.86, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.59, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUDESONIDE 1 MG/2ML IN SUSP", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "69097032187", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.02, "maximum": 13.41, "gross_charge": 14.27, "discounted_cash": 7.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.15, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.85, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.02, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.7, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.17, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUDESONIDE 180 MCG/ACT IN AEPB", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "61269051812", "type": "NDC" } ], "standard_charges": [ { "minimum": 236.37, "maximum": 788.45, "gross_charge": 838.78, "discounted_cash": 461.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 457.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 671.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 710.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.08, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 402.61, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 502.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 501.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 788.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 738.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 236.37, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 712.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 629.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 295.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 570.37, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 788.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 656.76, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 457.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 666.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 629.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 738.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 457.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUDESONIDE 3 MG PO CPEP", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "60687059632", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.16, "maximum": 30.55, "gross_charge": 32.5, "discounted_cash": 17.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.16, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.45, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.1, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUDESONIDE 90 MCG/ACT IN AEPB", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00186091706", "type": "NDC" } ], "standard_charges": [ { "minimum": 176.21, "maximum": 587.79, "gross_charge": 625.31, "discounted_cash": 343.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 362.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 500.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 529.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.97, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.15, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 374.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 373.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 587.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 550.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.21, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 531.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.3, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 425.21, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 587.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 489.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 497.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 550.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 362.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUDESONIDE-FORMOTEROL FUMARATE 160-4.5 MCG/ACT IN AERO", "drug_information": { "unit": "6.000000", "type": "GR" }, "code_information": [ { "code": "00186037028", "type": "NDC" } ], "standard_charges": [ { "minimum": 38.93, "maximum": 129.86, "gross_charge": 138.15, "discounted_cash": 75.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.2, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.31, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.93, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.67, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.17, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUDESONIDE-FORMOTEROL FUMARATE 80-4.5 MCG/ACT IN AERO", "drug_information": { "unit": "7.000000", "type": "GR" }, "code_information": [ { "code": "00186037228", "type": "NDC" } ], "standard_charges": [ { "minimum": 77.86, "maximum": 259.72, "gross_charge": 276.3, "discounted_cash": 151.97, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 234.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.62, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.86, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 234.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.34, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 219.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUMETANIDE 0.25 MG/ML IJ SOLN", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "68462046954_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUMETANIDE 0.25 MG/ML IJ SOLN|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "68462046954", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.02, "maximum": 3.41, "gross_charge": 3.63, "discounted_cash": 2.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.06, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.02, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.84, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUMETANIDE 0.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268013015", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUMETANIDE 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687038401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPIVACAINE 0.25 % INFUSION", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "00409155930_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPIVACAINE 0.25 % INFUSION|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "00409155930", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.58, "maximum": 18.6, "gross_charge": 19.79, "discounted_cash": 10.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.76, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.58, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.97, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.46, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPIVACAINE 0.75% 10 ML SDV (BULK CHARGE)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00409158210_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPIVACAINE 0.75% 10 ML SDV (BULK CHARGE)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00409158210", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.64, "maximum": 8.82, "gross_charge": 9.38, "discounted_cash": 5.16, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.73, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.25, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.64, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.3, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.38, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.25, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPIVACAINE HCL (PF) 0.25 % IJ SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00409115902", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - 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"Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPIVACAINE HCL (PF) 0.25% IJ SOLN 30ML VIAL (BULK CHARGE)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "55150016830", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, 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34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": 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charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPIVACAINE HCL (PF) 0.5 % IJ SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00409116201", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, 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"additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPIVACAINE HCL (PF) 0.5 % IJ SOLN 30ML VIAL (BULK CHARGE)", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "00409116202_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPIVACAINE HCL (PF) 0.5 % IJ SOLN 30ML VIAL (BULK CHARGE)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "00409116202", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.31, "maximum": 4.37, "gross_charge": 4.65, "discounted_cash": 2.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.35, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.23, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.64, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.16, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPIVACAINE HCL (PF) 0.75 % IJ SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00409158210_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All 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charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPIVACAINE HCL 0.5 % IJ SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00409161050", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00409176110", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPIVACAINE LIPOSOME 1.3 % IJ SUSP", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "65250026609", "type": "NDC" } ], "standard_charges": [ { "minimum": 378.69, "maximum": 1263.18, "gross_charge": 1343.81, "discounted_cash": 739.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 779.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 733.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1075.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1138.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 391.05, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 645.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 804.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue 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"payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPIVACAINE-EPINEPHRINE 0.5%-5MG/ML 30 ML (BULK CHARGE)", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "63323046237_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPRENORPHINE 10 MCG/HR TD PTWK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "42858049340", "type": "NDC" } ], "standard_charges": [ { "minimum": 29.27, "maximum": 97.63, "gross_charge": 103.86, "discounted_cash": 57.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.85, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.62, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPRENORPHINE 15 MCG/HR TD PTWK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "42858058640", "type": "NDC" } ], "standard_charges": [ { "minimum": 54.99, "maximum": 183.42, "gross_charge": 195.13, "discounted_cash": 107.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.66, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.99, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.74, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.69, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPRENORPHINE 20 MCG/HR TD PTWK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "42858083940", "type": "NDC" } ], "standard_charges": [ { "minimum": 76.28, "maximum": 254.44, "gross_charge": 270.68, "discounted_cash": 148.87, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.77, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.93, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.36, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.06, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 211.94, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPRENORPHINE 5 MCG/HR TD PTWK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00093365640", "type": "NDC" } ], "standard_charges": [ { "minimum": 33.79, "maximum": 112.72, "gross_charge": 119.91, "discounted_cash": 65.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.55, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.89, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.79, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.92, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.93, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.24, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.54, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.89, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.33, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.93, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.55, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPRENORPHINE 7.5 MCG/HR TD PTWK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00093323940", "type": "NDC" } ], "standard_charges": [ { "minimum": 57.55, "maximum": 191.98, "gross_charge": 204.23, "discounted_cash": 112.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.43, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 173.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.95, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00409201232", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPRENORPHINE HCL 2 MG SL SUBL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687048111", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPRENORPHINE HCL 2 MG SL SUBL (OPIOID WITHDRAWAL)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687048111_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPRENORPHINE HCL 8 MG SL SUBL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687049211", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPRENORPHINE HCL 8 MG SL SUBL (OPIOID WITHDRAWAL)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687049211_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL SUBL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00054018813", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL FILM", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "12496120803", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.73, "maximum": 19.11, "gross_charge": 20.33, "discounted_cash": 11.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.76, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.16, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.82, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "62175045832", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPROPION HCL 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687035101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPROPION HCL 75 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687034001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPROPION HCL ER (SR) 100 MG PO TB12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084069701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPROPION HCL ER (SR) 150 MG PO TB12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084070825", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPROPION HCL ER (XL) 150 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904708461", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.18, "maximum": 3.95, "gross_charge": 4.2, "discounted_cash": 2.31, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.02, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPROPION HCL ER (XL) 300 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687079321", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUROSUMAB-TWZA 10 MG/ML SC SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "42747010201", "type": "NDC" } ], "standard_charges": [ { "minimum": 256.39, "maximum": 12553.09, "gross_charge": 13354.35, "discounted_cash": 7344.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7745.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 256.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10683.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11311.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3886.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6410.09, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7999.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7985.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12553.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11751.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3763.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11351.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10015.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4704.74, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9080.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12553.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10456.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": 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}, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21366.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22622.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7772.24, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12820.19, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15998.53, 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"standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15491.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 256.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BUROSUMAB-TWZA 30 MG/ML SC SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "42747030401", "type": "NDC" } ], "standard_charges": [ { "minimum": 256.39, "maximum": 37659.3, "gross_charge": 40063.08, "discounted_cash": 22034.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", 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charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11289.78, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34053.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30047.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14114.22, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": 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"plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30047.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35255.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23236.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 256.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BUSPIRONE HCL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079098620", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUSPIRONE HCL 15 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687082301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUSPIRONE HCL 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079098520", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUSULFAN 6 MG/ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "71288011611", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.69, "maximum": 69.39, "gross_charge": 73.82, "discounted_cash": 40.6, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.69, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.48, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.43, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.8, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.01, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.8, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.69, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.69, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BUTAMBEN-TETRACAINE-BENZOCAINE 2-2-14 % EX AERO", "drug_information": { "unit": "20.000000", "type": "GR" }, "code_information": [ { "code": "10223020103", "type": "NDC" } ], "standard_charges": [ { "minimum": 85.17, "maximum": 284.12, "gross_charge": 302.25, "discounted_cash": 166.24, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 241.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 256.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.95, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.08, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 180.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 265.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.17, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 256.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.53, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 236.66, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.29, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 265.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUTORPHANOL TARTRATE 10 MG/ML NA SOLN", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "60505081301", "type": "NDC" } ], "standard_charges": [ { "minimum": 35.99, "maximum": 120.07, "gross_charge": 127.73, "discounted_cash": 70.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.31, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.99, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.0, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.86, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.01, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUTORPHANOL TARTRATE 2 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00409162601", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUTT BALM OINTMENT WITH CHOLESTYRAMINE 10%", "drug_information": { "unit": "50.000000", "type": "GR" }, "code_information": [ { "code": "P8252100050", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.0, "maximum": 1158.0, "gross_charge": 35.47, "discounted_cash": 19.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.79, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.32, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bx breast 1st lesion mr imag", "code_information": [ { "code": "19085", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3764.64, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6831.01, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6831.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bx breast 1st lesion strtctc", "code_information": [ { "code": "19081", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3625.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6579.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6579.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bx breast 1st lesion us imag", "code_information": [ { "code": "19083", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3576.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6489.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6489.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bx breast percut w/o image", "code_information": [ { "code": "19100", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8446.88, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15327.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15327.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bx of cervix w/scope leep", "code_information": [ { "code": "57460", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7650.21, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13888.63, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13888.63, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bx/curett of cervix w/scope", "code_information": [ { "code": "57454", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 224.22, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1902.65, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3456.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3456.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bx/exc xdrl spine lesn lmbr", "code_information": [ { "code": "63277", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21820.29, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39593.27, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39593.27, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "C-laminoplasty w/graft/plate", "code_information": [ { "code": "63051", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 48218.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 87493.1, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 87493.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "C1 ESTERASE INHIBITOR (HUMAN) 500 UNITS IV KIT", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63833082502", "type": "NDC" } ], "standard_charges": [ { "minimum": 2940.39, "maximum": 9808.27, "gross_charge": 10434.33, "discounted_cash": 5738.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6051.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5697.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8347.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8837.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3036.39, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5008.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6250.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6239.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9808.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9182.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2940.39, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8869.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7825.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3676.01, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7095.34, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9808.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8170.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5697.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8295.29, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7825.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9182.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6051.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5697.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ca screen;flexi sigmoidscope", "code_information": [ { "code": "G0104", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 672.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 497.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2470.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4482.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4482.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CABAZITAXEL 60 MG/1.5ML IV SOLN", "drug_information": { "unit": "6.000000", "type": "UN" }, "code_information": [ { "code": "00024582411", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 39893.21, "gross_charge": 42439.59, "discounted_cash": 23341.77, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24614.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23172.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33951.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35946.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12349.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20371.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25421.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39893.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37346.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11959.48, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36073.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31829.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14951.47, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28858.92, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39893.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33230.2, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23172.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31829.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37346.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24614.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23172.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CABERGOLINE 0.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "2315582373", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.76, "maximum": 9.21, "gross_charge": 9.8, "discounted_cash": 5.39, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.85, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.7, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.45, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.67, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CADEXOMER IODINE 0.9 % EX GEL", "drug_information": { "unit": "40.000000", "type": "GR" }, "code_information": [ { "code": "40565012249", "type": "NDC" } ], "standard_charges": [ { "minimum": 63.11, "maximum": 210.51, "gross_charge": 223.95, "discounted_cash": 123.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.11, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.9, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.29, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CAFFEINE 200 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "46122045773", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CAFFEINE CITRATE 60 MG/3ML (IV FOR PO)", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "25021060103", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.79, "maximum": 9.31, "gross_charge": 9.9, "discounted_cash": 5.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.75, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.79, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.73, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.87, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CAFFEINE CITRATE 60 MG/3ML IV SOLN", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "25021060103_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CAFFEINE-SODIUM BENZOATE 125-125 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00517250210", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALAMINE-ZINC OXIDE 8-8 % EX LOTN", "drug_information": { "unit": "177.000000", "type": "UN" }, "code_information": [ { "code": "00904253321", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed 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"standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", 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"Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "72694051501", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 70593.4, "gross_charge": 75099.36, "discounted_cash": 41304.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 43557.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 41004.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60079.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63609.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21853.91, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36047.69, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44984.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70593.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66087.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21163.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63834.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56324.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 26457.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51067.56, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 70593.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58802.8, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41004.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56324.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66087.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43557.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41004.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCITONIN (SALMON) 200 UNIT/ACT NA SOLN", "drug_information": { "unit": "3.700000", "type": "UN" }, "code_information": [ { "code": "60505082306", "type": "NDC" } ], "standard_charges": [ { "minimum": 41.06, "maximum": 136.96, "gross_charge": 145.7, "discounted_cash": 80.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.94, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.06, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.33, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.08, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "42023020501", "type": "NDC" } ], "standard_charges": [ { "minimum": 640.49, "maximum": 2605.15, "gross_charge": 2771.44, "discounted_cash": 1524.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1607.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 640.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2217.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2347.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 806.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1330.29, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1660.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1657.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2605.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2438.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 780.99, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2355.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2078.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 976.38, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1884.58, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2605.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2170.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 864.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2203.29, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2078.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2438.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1607.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 640.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "CALCITRIOL 0.25 MCG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687034501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCITRIOL 0.5 MCG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R6945220820", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCITRIOL 1 MCG/ML PO SOLN", "drug_information": { "unit": "0.250000", "type": "UN" }, "code_information": [ { "code": "64980044715", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.26, "maximum": 14.19, "gross_charge": 15.1, "discounted_cash": 8.31, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.39, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.25, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.32, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.27, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.82, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM ACETATE (PHOS BINDER) 667 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084047901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM CARB-CHOLECALCIFEROL 250-3.125 MG-MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "20555002500", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM CARBONATE 1500 (600 CA) MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "80681000500", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM CARBONATE ANTACID 500 (200 CA) MG PO CHEW", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084098832", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM CHLORIDE 10 % IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00517671010", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM CHLORIDE 10 % IV SOLN -CODE USE PEDS", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "76329330401", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM CHLORIDE 10 % IV SOLN 10 ML SYRINGE (BULK CHARGE)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "76329330401_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM CHLORIDE 10 % IV SOLN 10 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00517671010_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM CHLORIDE 10 % IV SOLN EXCHANGE TRANSFUSION (NICU)", "drug_information": { "unit": "0.330000", "type": "UN" }, "code_information": [ { "code": "00517671010_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM CHLORIDE 10% IV SOLN FOR PCTU", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00517671010_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM CHLORIDE IVPB (APHERESIS)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "08252000179", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM CHLORIDE IVPB (APHERESIS) PRN", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "08252000179_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM CITRATE 950 (200 CA) MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "80681014000", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE (ANTIDOTE) 2.5 % EX GEL", "drug_information": { "unit": "25.000000", "type": "GR" }, "code_information": [ { "code": "35181730332", "type": "NDC" } ], "standard_charges": [ { "minimum": 22.64, "maximum": 75.51, "gross_charge": 80.33, "discounted_cash": 44.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.69, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.64, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.3, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.62, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.9, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.69, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE 10 % IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "63323036019_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE 10 % IV SOLN (APHERESIS)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "63323036019_6", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE 10 % IV SOLN (NICU)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323036019_7", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE 10 % IV SOLN (NICU)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323036019", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.1, "maximum": 17.0, "gross_charge": 18.09, "discounted_cash": 9.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.68, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE 10 % IV SOLN 10 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323036019_8", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE 10 % IV SOLN 10 ML VIAL (BULK CHARGE)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323036019_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.1, "maximum": 17.0, "gross_charge": 18.09, "discounted_cash": 9.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.68, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE 10 % IV SOLN FOR HYPERKALEMIA", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323036019_9", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE 10 % IV SOLN FOR HYPERKALEMIA|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323036019_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.1, "maximum": 17.0, "gross_charge": 18.09, "discounted_cash": 9.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.68, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE 10% DRIP (PEDS)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323036019_10", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE 10% DRIP (PEDS)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323036019_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.1, "maximum": 17.0, "gross_charge": 18.09, "discounted_cash": 9.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.68, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE 20 MG/ML PERIPHERAL (PICU/NICU) IV SYRINGE FROM RTU", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "44567062024_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE 20 MG/ML PERIPHERAL (PICU/NICU) IV SYRINGE FROM RTU|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "44567062024_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.46, "maximum": 18.2, "gross_charge": 19.36, "discounted_cash": 10.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.63, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.29, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.16, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE 20 MG/ML PERIPHERAL (PICU/NICU) IVPB FROM RTU", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "44567062024_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 1158.0, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.48, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE 20 MG/ML PERIPHERAL (PICU/NICU) IVPB FROM RTU|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "44567062024", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.46, "maximum": 1158.0, "gross_charge": 19.36, "discounted_cash": 10.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.8, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.63, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.29, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.16, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE IVPB (APHERESIS)", "drug_information": { "unit": "25.000000", "type": "UN" }, "code_information": [ { "code": "08252000073", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE IVPB RTU (APHERESIS)", "drug_information": { "unit": "25.000000", "type": "UN" }, "code_information": [ { "code": "44567062024_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE-NACL 1-0.675 GM/50ML-% IV SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "44567062024_6", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM POLYCARBOPHIL 625 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00536430608", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CANAKINUMAB 150 MG/ML SC SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078073461", "type": "NDC" } ], "standard_charges": [ { "minimum": 69.78, "maximum": 54831.69, "gross_charge": 58331.58, "discounted_cash": 32082.37, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 33832.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46665.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49406.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16974.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27999.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34940.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54831.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51331.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16437.84, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49581.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43748.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20550.22, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39665.47, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 54831.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45673.63, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43748.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51331.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33832.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "CANDESARTAN CILEXETIL 16 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687024125", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.2, "maximum": 7.32, "gross_charge": 7.79, "discounted_cash": 4.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.23, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.74, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.1, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CANDESARTAN CILEXETIL 32 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687013025", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.83, "maximum": 9.44, "gross_charge": 10.04, "discounted_cash": 5.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.03, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.83, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.54, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.83, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.86, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CANDESARTAN CILEXETIL 4 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "33342011407", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CANDIDA ALBICANS SKN TST ANTGN ID SOLN", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "59584013801", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.89, "maximum": 1158.0, "gross_charge": 67.02, "discounted_cash": 36.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.17, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.89, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.61, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CANGRELOR TETRASODIUM 50 MG IV SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "10122062010", "type": "NDC" } ], "standard_charges": [ { "minimum": 972.34, "maximum": 3243.44, "gross_charge": 3450.47, "discounted_cash": 1897.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2001.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2760.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2922.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1004.09, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1656.23, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2066.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2063.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3243.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3036.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 972.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2932.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2587.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1215.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2346.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3243.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2701.72, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2743.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2587.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3036.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2001.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CANNABIDIOL 100 MG/ML PO SOLN", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "70127010060", "type": "NDC" } ], "standard_charges": [ { "minimum": 691.11, "maximum": 2305.35, "gross_charge": 2452.5, "discounted_cash": 1348.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1422.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1339.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1962.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2077.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 713.68, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1177.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1469.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1466.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2305.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2158.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.11, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2084.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1839.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 864.02, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1667.7, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2305.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1920.31, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1339.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1949.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1839.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2158.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1422.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1339.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cannula declotting", "code_information": [ { "code": "36861", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3984.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2951.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15144.51, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27479.96, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3984.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27479.96, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CAPECITABINE 150 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "55111049660_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CAPECITABINE 150 MG PO TABS|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "55111049660", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.15, "maximum": 0.51, "gross_charge": 0.54, "discounted_cash": 0.3, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.26, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.19, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.37, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.42, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CAPECITABINE 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687014994", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.03, "maximum": 4.34, "gross_charge": 4.62, "discounted_cash": 2.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.03, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.34, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.22, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.3, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.63, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.14, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.04, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.03, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "CAPSAICIN 0.025 % EX CREA", "drug_information": { "unit": "60.000000", "type": "GR" }, "code_information": [ { "code": "00536252525", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.0, "maximum": 6.66, "gross_charge": 7.08, "discounted_cash": 3.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.06, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.81, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.54, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.63, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CAPSAICIN 0.075 % EX CREA", "drug_information": { "unit": "57.000000", "type": "GR" }, "code_information": [ { "code": "00536111825", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.0, "maximum": 9.99, "gross_charge": 10.63, "discounted_cash": 5.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.09, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.74, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.23, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CAPTOPRIL 1 MG/ML ORAL SUSPENSION", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "P0143117401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.34, "maximum": 4.47, "gross_charge": 4.75, "discounted_cash": 2.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.18, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.67, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.23, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.72, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.18, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CAPTOPRIL 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R6929252801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CAPTOPRIL 12.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687030421", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CAPTOPRIL 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687031521", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CAPTOPRIL 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R6929252601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.18, "maximum": 3.95, "gross_charge": 4.2, "discounted_cash": 2.31, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.02, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CAPTOPRIL 6.25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0143117101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBACHOL 0.01 % IO SOLN", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "00065002315", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBAMAZEPINE 100 MG PO CHEW", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687047901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBAMAZEPINE 100 MG/5ML PO SUSP", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "17856404701", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.74, "maximum": 9.14, "gross_charge": 9.72, "discounted_cash": 5.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.83, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.67, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.42, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.61, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.61, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBAMAZEPINE 200 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084044401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBAMAZEPINE ER 100 MG PO CP12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "66993040732", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBAMAZEPINE ER 100 MG PO TB12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00832602211", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBAMAZEPINE ER 200 MG PO CP12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "66993040832", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBAMAZEPINE ER 200 MG PO TB12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687058321", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.65, "maximum": 5.5, "gross_charge": 5.85, "discounted_cash": 3.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.81, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.15, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.65, "standard_charge_percentage": 28.0,